- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.32 / $4,463.68 / $7,993.22
| Facility | | $402.32 | $4,463.68 | $7,993.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $3,306.43
| Professional | | $402.32 | $402.32 | $3,306.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.01 / $20.01 / $20.01
| Professional | | $20.01 | $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 / $1,353.81
| Professional | | $1,054.93 | $1,054.93 | $1,353.81 |