- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $2,818.38 / $5,888.44
| Facility | | $851.14 | $2,818.38 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,073.80 / $5,888.44
| Facility | | $3,388.44 | $4,073.80 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $1,513.56
| Professional | | $724.44 | $1,047.13 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,995.26 / $6,309.57
| Facility | | $724.44 | $1,995.26 | $6,309.57 |