- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $3,090.30 / $6,760.83
| Facility | | $316.23 | $3,090.30 | $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
- $173.78 / $371.54 / $933.25
| Professional | | $173.78 | $371.54 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $457.09 / $5,011.87
| Facility | | $218.78 | $457.09 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $467.74 / $501.19
| Professional | | $363.08 | $467.74 | $501.19 |
- 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 |