- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $1,479.11 / $6,918.31
| Facility | | $331.13 | $1,479.11 | $6,918.31 |
- 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
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $602.56 / $1,258.93
| Facility | | $204.17 | $602.56 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $758.58 / $1,949.84
| Facility | | $173.78 | $758.58 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $6,456.54 / $6,456.54
| Facility | | $56.23 | $6,456.54 | $6,456.54 |