- 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
- $3,388.44 / $4,073.80 / $5,888.44
| Facility | | $3,388.44 | $4,073.80 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.76 / $794.33 / $1,174.90
| Professional | | $6.76 | $794.33 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $1,288.25 / $2,041.74
| Facility | | $199.53 | $1,288.25 | $2,041.74 |