- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $5,888.44 / $7,943.28
| Facility | | $602.56 | $5,888.44 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $7,079.46 / $21,379.62
| Professional | | $2,630.27 | $7,079.46 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $707.95 / $2,137.96
| Facility | | $363.08 | $707.95 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,202.26 / $2,344.23
| Facility | | $512.86 | $1,202.26 | $2,344.23 |