- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $742.27 / $1,358.35 / $1,833.77
| Facility | | $742.27 | $1,358.35 | $1,833.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.39 / $586.39 / $853.61
| Professional | | $586.39 | $586.39 | $853.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $964.95 / $1,002.06 / $1,002.06
| Facility | | $964.95 | $1,002.06 | $1,002.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.51 / $2,059.51 / $2,059.51
| Professional | | $2,059.51 | $2,059.51 | $2,059.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Professional | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.75 / $445.36 / $1,261.85
| Professional | | $311.75 | $445.36 | $1,261.85 |