- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,089.30 / $5,011.87
| Facility | | $758.58 | $2,089.30 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,025.60 / $7,762.47
| Facility | | $3,715.35 | $6,025.60 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.98 / $724.44 / $2,041.74
| Professional | | $3.98 | $724.44 | $2,041.74 |
- 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 |