- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $2,630.27 / $7,762.47
| Facility | | $524.81 | $2,630.27 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,754.23 / $4,466.84
| Facility | | $1,258.93 | $2,754.23 | $4,466.84 |
- 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
- $295.12 / $812.83 / $1,479.11
| Professional | | $295.12 | $812.83 | $1,479.11 |
- 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 |