- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,230.27 / $8,709.64
| Facility | | $758.58 | $1,230.27 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,318.26
| Professional | | $1,288.25 | $1,288.25 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $912.01 / $1,202.26
| Facility | | $676.08 | $912.01 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $3,890.45 / $6,918.31
| Facility | | $1,174.90 | $3,890.45 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $4,786.30 / $4,786.30
| Facility | | $56.23 | $4,786.30 | $4,786.30 |