- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,248.07 / $5,248.07
| Facility | | $4,168.69 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $309.03 / $1,698.24
| Professional | | $87.10 | $309.03 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $269.15 / $2,398.83
| Professional | | $199.53 | $269.15 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $831.76 / $3,162.28
| Professional | | $125.89 | $831.76 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $3,090.30
| Facility | | $295.12 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $851.14 / $4,168.69
| Professional | | $147.91 | $851.14 | $4,168.69 |