- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $3,630.78 / $8,511.38
| Facility | | $549.54 | $3,630.78 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,174.90 / $2,290.87
| Facility | | $891.25 | $1,174.90 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $630.96 / $1,380.38
| Facility | | $363.08 | $630.96 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $851.14 / $1,380.38
| Professional | | $602.56 | $851.14 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,819.70 / $6,309.57
| Facility | | $870.96 | $1,819.70 | $6,309.57 |