- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $2,398.83 / $6,606.93
| Facility | | $776.25 | $2,398.83 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $891.25 / $2,238.72
| Professional | | $218.78 | $891.25 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,445.44 / $2,041.74
| Facility | | $676.08 | $1,445.44 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $56.23 / $56.23
| Facility | | $54.95 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,803.84 / $13,803.84 / $13,803.84
| Professional | | $13,803.84 | $13,803.84 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $812.83 / $2,511.89
| Facility | | $295.12 | $812.83 | $2,511.89 |