- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $1,548.82 / $5,623.41
| Facility | | $363.08 | $1,548.82 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,168.69 / $5,495.41
| Facility | | $2,398.83 | $4,168.69 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $537.03 / $1,548.82
| Professional | | $288.40 | $537.03 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,630.78 / $7,079.46
| Facility | | $1,513.56 | $3,630.78 | $7,079.46 |