- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $3,235.94 / $7,762.47
| Facility | | $588.84 | $3,235.94 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,754.23 / $4,365.16
| Facility | | $1,258.93 | $2,754.23 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,698.24 / $4,466.84
| Facility | | $398.11 | $1,698.24 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $549.54 / $2,089.30
| Professional | | $288.40 | $549.54 | $2,089.30 |
- 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 |