- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $603.41 / $685.62 / $724.09
| Facility | | $603.41 | $685.62 | $724.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.71 / $363.71 / $435.77
| Professional | | $363.71 | $363.71 | $435.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.00 / $365.00 / $365.00
| Professional | | $365.00 | $365.00 | $365.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $372.66 / $508.43 / $1,684.20
| Facility | | $372.66 | $508.43 | $1,684.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,239.82 / $3,239.82 / $3,239.82
| Professional | | $3,239.82 | $3,239.82 | $3,239.82 |