- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $2,570.40 / $6,760.83
| Facility | | $257.04 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $251.19 / $501.19
| Professional | | $144.54 | $251.19 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $338.84 / $5,011.87
| Facility | | $158.49 | $338.84 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $354.81 / $416.87
| Professional | | $251.19 | $354.81 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,786.30 / $6,309.57
| Facility | | $2,511.89 | $4,786.30 | $6,309.57 |