- 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
- $3,235.94 / $3,235.94 / $3,235.94
| Professional | | $3,235.94 | $3,235.94 | $3,235.94 |
- 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
- $1,023.29 / $1,819.70 / $4,677.35
| Facility | | $1,023.29 | $1,819.70 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,137.96 / $4,897.79
| Facility | | $1,096.48 | $2,137.96 | $4,897.79 |