- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $1,288.25 / $5,623.41
| Facility | | $331.13 | $1,288.25 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,548.82 / $2,041.74
| Facility | | $758.58 | $1,548.82 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,698.24 / $2,754.23
| Facility | | $302.00 | $1,698.24 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $691.83 / $1,174.90
| Professional | | $109.65 | $691.83 | $1,174.90 |
- 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 / $4,570.88
| Facility | | $891.25 | $2,238.72 | $4,570.88 |