- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $3,235.94 / $9,772.37
| Facility | | $478.63 | $3,235.94 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,884.03 / $5,495.41
| Facility | | $1,047.13 | $2,884.03 | $5,495.41 |
- 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
- $269.15 / $537.03 / $1,288.25
| Professional | | $269.15 | $537.03 | $1,288.25 |
- 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
- $1,905.46 / $4,897.79 / $11,481.54
| Facility | | $1,905.46 | $4,897.79 | $11,481.54 |