- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $2,511.89 / $6,760.83
| Facility | | $245.47 | $2,511.89 | $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
- $138.04 / $1,023.29 / $1,445.44
| Professional | | $138.04 | $1,023.29 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.93 / $1,348.96 / $4,265.80
| Facility | | $208.93 | $1,348.96 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $1,905.46 / $2,187.76
| Professional | | $354.81 | $1,905.46 | $2,187.76 |
- 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 |