- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.64 / $1,357.20 / $1,832.22
| Facility | | $741.64 | $1,357.20 | $1,832.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.23 / $556.23 / $556.23
| Professional | | $556.23 | $556.23 | $556.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $964.13 / $1,001.21 / $1,001.21
| Facility | | $964.13 | $1,001.21 | $1,001.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.41 / $1,156.41 / $1,156.41
| Professional | | $1,156.41 | $1,156.41 | $1,156.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $42.50
| Professional | | $17.00 | $20.00 | $42.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.49 / $444.98 / $1,112.46
| Professional | | $311.49 | $444.98 | $1,112.46 |