- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $3,090.30 / $8,511.38
| Facility | | $275.42 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,698.24 / $3,235.94
| Facility | | $630.96 | $1,698.24 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $588.84
| Facility | | $398.11 | $398.11 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $275.42 / $1,096.48
| Professional | | $158.49 | $275.42 | $1,096.48 |
- 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
- $562.34 / $2,818.38 / $7,413.10
| Facility | | $562.34 | $2,818.38 | $7,413.10 |