- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $722.46 / $5,460.00 / $9,785.76
| Facility | | $722.46 | $5,460.00 | $9,785.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $402.32
| Professional | | $402.32 | $402.32 | $402.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.01 / $20.01
| Professional | | $17.00 | $20.01 | $20.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.42 / $104.42 / $104.42
| Facility | | $104.42 | $104.42 | $104.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.93 / $1,054.93 / $1,054.93
| Professional | | $1,054.93 | $1,054.93 | $1,054.93 |