- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $2,511.89 / $6,760.83
| Facility | | $218.78 | $2,511.89 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $501.19 / $1,047.13
| Professional | | $128.82 | $501.19 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $436.52 / $4,677.35
| Facility | | $186.21 | $436.52 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $630.96 / $1,000.00
| Professional | | $269.15 | $630.96 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,248.07 / $7,413.10
| Facility | | $2,511.89 | $5,248.07 | $7,413.10 |