- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $4,365.16 / $7,943.28
| Facility | | $239.88 | $4,365.16 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $724.44
| Professional | | $398.11 | $398.11 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $302.00 / $478.63
| Facility | | $158.49 | $302.00 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,467.37 / $6,606.93
| Facility | | $1,230.27 | $3,467.37 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $45,708.82
| Facility | | $6,760.83 | $6,760.83 | $45,708.82 |