- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $690.18 / $2,373.46 / $6,232.98
| Facility | | $690.18 | $2,373.46 | $6,232.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $690.18 / $839.19
| Professional | | $150.00 | $690.18 | $839.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.71 / $627.71 / $834.85
| Professional | | $627.71 | $627.71 | $834.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.52 / $240.52 / $610.54
| Professional | | $240.52 | $240.52 | $610.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.68 / $437.68 / $437.68
| Professional | | $437.68 | $437.68 | $437.68 |