- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $727.33 / $1,518.41 / $3,955.04
| Facility | | $727.33 | $1,518.41 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.92 / $4,020.80 / $8,336.29
| Professional | | $2,035.92 | $4,020.80 | $8,336.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.28 / $397.75 / $530.82
| Facility | | $181.28 | $397.75 | $530.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $680.00 / $680.00
| Facility | | $680.00 | $680.00 | $680.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.00 / $1,183.00 / $4,915.00
| Facility | | $320.00 | $1,183.00 | $4,915.00 |