- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $5,888.44
| Facility | | $933.25 | $2,691.53 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,137.96 / $2,951.21
| Professional | | $1,659.59 | $2,137.96 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $4,570.88 / $8,912.51
| Facility | | $0.02 | $4,570.88 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,754.23 / $6,606.93
| Facility | | $831.76 | $2,754.23 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,951.21 / $5,128.61
| Professional | | $2,290.87 | $2,951.21 | $5,128.61 |