- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $2,290.87 / $7,762.47
| Facility | | $436.52 | $2,290.87 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,754.23 / $3,890.45
| Facility | | $1,258.93 | $2,754.23 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,698.24 / $2,754.23
| Facility | | $398.11 | $1,698.24 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $691.83 / $1,258.93
| Professional | | $251.19 | $691.83 | $1,258.93 |
- 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 |