- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $690.18 / $1,649.49 / $4,208.14
| Facility | | $690.18 | $1,649.49 | $4,208.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.18 / $690.18 / $690.18
| Professional | | $690.18 | $690.18 | $690.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,645.04 / $2,645.04 / $2,645.04
| Professional | | $2,645.04 | $2,645.04 | $2,645.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.52 / $240.52 / $240.52
| Professional | | $240.52 | $240.52 | $240.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $808.34 / $841.00 / $1,179.21
| Facility | | $808.34 | $841.00 | $1,179.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.37 / $1,384.37 / $1,384.37
| Professional | | $1,384.37 | $1,384.37 | $1,384.37 |