- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,047.13 / $1,995.26
| Facility | | $501.19 | $1,047.13 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $933.25 / $1,230.27
| Professional | | $223.87 | $933.25 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $457.09
| Professional | | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $42.66 / $79.43
| Professional | | $21.38 | $42.66 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,621.81 / $5,370.32
| Facility | | $630.96 | $1,621.81 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,148.15 / $1,621.81
| Professional | | $575.44 | $1,148.15 | $1,621.81 |