- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $2,187.76 / $5,888.44
| Facility | | $446.68 | $2,187.76 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,630.27 / $3,630.78
| Facility | | $1,258.93 | $2,630.27 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $588.84 / $1,698.24
| Facility | | $398.11 | $588.84 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $616.60 / $1,047.13
| Professional | | $218.78 | $616.60 | $1,047.13 |
- 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 / $2,238.72 / $4,786.30
| Facility | | $891.25 | $2,238.72 | $4,786.30 |