- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $2,187.76 / $5,888.44
| Facility | | $512.86 | $2,187.76 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,754.23 / $3,981.07
| Facility | | $1,258.93 | $2,754.23 | $3,981.07 |
- 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
- $263.03 / $446.68 / $1,445.44
| Professional | | $263.03 | $446.68 | $1,445.44 |
- 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 |