- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $836.47 / $2,305.77 / $6,539.17
| Facility | | $836.47 | $2,305.77 | $6,539.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,032.19
| Professional | | $836.47 | $836.47 | $1,032.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $360.74
| Professional | | $360.74 | $360.74 | $360.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $893.07 / $1,113.58 / $1,598.71
| Facility | | $893.07 | $1,113.58 | $1,598.71 |