- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $1,862.09 / $7,762.47
| Facility | | $331.13 | $1,862.09 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,570.40 / $3,630.78
| Facility | | $1,202.26 | $2,570.40 | $3,630.78 |
- 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
- $223.87 / $416.87 / $1,548.82
| Professional | | $223.87 | $416.87 | $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
- $891.25 / $2,290.87 / $4,786.30
| Facility | | $891.25 | $2,290.87 | $4,786.30 |