- 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
- $602.56 / $645.65 / $1,380.38
| Professional | | $602.56 | $645.65 | $1,380.38 |
- 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 / $25.12 / $50.12
| Professional | | $21.38 | $25.12 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $2,089.30 / $7,244.36
| Facility | | $851.14 | $2,089.30 | $7,244.36 |