- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $1,778.28 / $4,073.80
| Facility | | $467.74 | $1,778.28 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $2,137.96 / $3,467.37
| Professional | | $186.21 | $2,137.96 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,513.56 / $2,137.96
| Facility | | $691.83 | $1,513.56 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $56.23 / $56.23
| Facility | | $54.95 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Professional | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $812.83 / $2,511.89
| Facility | | $295.12 | $812.83 | $2,511.89 |