- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $2,691.53 / $5,623.41
| Facility | | $467.74 | $2,691.53 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,754.23 / $4,073.80
| Facility | | $1,258.93 | $2,754.23 | $4,073.80 |
- 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
- $269.15 / $457.09 / $1,548.82
| Professional | | $269.15 | $457.09 | $1,548.82 |
- 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 |