- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $2,187.76 / $7,762.47
| Facility | | $380.19 | $2,187.76 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,548.13 / $4,786.30
| Facility | | $1,905.46 | $3,548.13 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,511.89 / $2,754.23
| Facility | | $398.11 | $2,511.89 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $870.96 / $1,513.56
| Professional | | $213.80 | $870.96 | $1,513.56 |
- 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 / $2,290.87 / $5,128.61
| Facility | | $891.25 | $2,290.87 | $5,128.61 |