- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,089.30 / $5,248.07
| Facility | | $758.58 | $2,089.30 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,073.80 / $5,888.44
| Facility | | $3,388.44 | $4,073.80 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $1,230.27
| Facility | | $912.01 | $912.01 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $870.96 / $1,230.27
| Professional | | $112.20 | $870.96 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $933.25
| Facility | | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,949.84 / $6,309.57
| Facility | | $724.44 | $1,949.84 | $6,309.57 |