- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $1,698.24 / $6,456.54
| Facility | | $295.12 | $1,698.24 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,570.40 / $3,388.44
| Facility | | $1,202.26 | $2,570.40 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $7,762.47 / $10,964.78
| Facility | | $6,309.57 | $7,762.47 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $478.63 / $1,122.02
| Professional | | $204.17 | $478.63 | $1,122.02 |
- 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
- $891.25 / $2,290.87 / $4,786.30
| Facility | | $891.25 | $2,290.87 | $4,786.30 |