- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,818.38 / $5,888.44
| Facility | | $575.44 | $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
- $4.68 / $691.83 / $1,148.15
| Professional | | $4.68 | $691.83 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,344.23 / $7,244.36
| Facility | | $1,288.25 | $2,344.23 | $7,244.36 |