- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $759.05 / $1,381.47 / $1,518.10
| Facility | | $759.05 | $1,381.47 | $1,518.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.65 / $1,381.47 / $1,518.10
| Professional | | $599.65 | $1,381.47 | $1,518.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $986.77 / $1,024.72 / $1,024.72
| Facility | | $986.77 | $1,024.72 | $1,024.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $25.00 / $50.00
| Professional | | $21.25 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.80 / $455.43 / $1,295.68
| Professional | | $318.80 | $455.43 | $1,295.68 |