- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $3,235.94 / $9,772.37
| Facility | | $346.74 | $3,235.94 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,041.74 / $3,890.45
| Facility | | $758.58 | $2,041.74 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $302.00 / $1,122.02
| Professional | | $190.55 | $302.00 | $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
- $575.44 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |