- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.49 / $1,698.24 / $5,011.87
| Facility | | $117.49 | $1,698.24 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,467.37 / $4,466.84
| Facility | | $1,513.56 | $3,467.37 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.28 / $81.28 / $81.28
| Facility | | $81.28 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.45 / $131.83 / $199.53
| Professional | | $1.45 | $131.83 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $1,288.25 / $2,041.74
| Facility | | $199.53 | $1,288.25 | $2,041.74 |