- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $6,606.93
| Facility | | $933.25 | $2,691.53 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,096.48 / $1,380.38
| Professional | | $977.24 | $1,096.48 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Facility | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $7,079.46 / $18,620.87
| Facility | | $1,202.26 | $7,079.46 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,380.38 / $2,754.23
| Professional | | $977.24 | $1,380.38 | $2,754.23 |