- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,454.71 / $6,606.93
| Facility | | $758.58 | $2,454.71 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.29 / $51.29 / $75.86
| Professional | | $51.29 | $51.29 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,174.90 / $1,905.46
| Facility | | $758.58 | $1,174.90 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Professional | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.29 / $575.44 / $1,659.59
| Facility | | $51.29 | $575.44 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $630.96 / $1,659.59
| Facility | | $138.04 | $630.96 | $1,659.59 |