- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $3,235.94 / $7,762.47
| Facility | | $204.17 | $3,235.94 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,818.38 / $4,786.30
| Facility | | $1,047.13 | $2,818.38 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,288.25 / $2,398.83
| Facility | | $398.11 | $1,288.25 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $323.59 / $562.34
| Professional | | $123.03 | $323.59 | $562.34 |
- 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 |