- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $564.75 / $2,355.51 / $2,543.88
| Facility | | $564.75 | $2,355.51 | $2,543.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.81 / $152.03 / $369.75
| Professional | | $151.81 | $152.03 | $369.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.69 / $208.18 / $458.53
| Professional | | $184.69 | $208.18 | $458.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,302.86 / $1,302.86 / $2,381.69
| Facility | | $1,302.86 | $1,302.86 | $2,381.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.00 / $171.12 / $330.00
| Professional | | $105.00 | $171.12 | $330.00 |