- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,290.87 / $5,370.32
| Facility | | $575.44 | $2,290.87 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,778.28
| Professional | | $1,698.24 | $1,698.24 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,513.56 / $2,238.72
| Facility | | $691.83 | $1,513.56 | $2,238.72 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $812.83 / $2,511.89
| Facility | | $295.12 | $812.83 | $2,511.89 |