- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $7,244.36
| Facility | | $3,235.94 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $2,344.23 / $6,456.54
| Professional | | $162.18 | $2,344.23 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $323.59 / $5,128.61
| Professional | | $194.98 | $323.59 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $2,570.40 / $5,011.87
| Professional | | $177.83 | $2,570.40 | $5,011.87 |