- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $4,365.16 / $14,791.08
| Facility | | $812.83 | $4,365.16 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Professional | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $91.20 / $162.18
| Professional | | $66.07 | $91.20 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,348.96
| Facility | | $812.83 | $812.83 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,248.07 / $10,964.78
| Facility | | $1,737.80 | $5,248.07 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,248.07 / $10,964.78
| Professional | | $1,737.80 | $5,248.07 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,388.44 / $7,079.46
| Facility | | $1,584.89 | $3,388.44 | $7,079.46 |