- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.11 / $1,014.59 / $1,813.20
| Facility | | $253.11 | $1,014.59 | $1,813.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $839.19 / $1,010.42
| Professional | | $150.00 | $839.19 | $1,010.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $657.71 / $657.71 / $657.71
| Facility | | $657.71 | $657.71 | $657.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,012.86 / $1,012.86 / $1,012.86
| Facility | | $1,012.86 | $1,012.86 | $1,012.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.52 / $240.52 / $610.54
| Professional | | $240.52 | $240.52 | $610.54 |