- 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
- $7,413.10 / $7,413.10 / $7,413.10
| Professional | | $7,413.10 | $7,413.10 | $7,413.10 |
- 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
- $3,019.95 / $5,128.61 / $7,244.36
| Facility | | $3,019.95 | $5,128.61 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,128.61 / $7,244.36
| Facility | | $3,019.95 | $5,128.61 | $7,244.36 |