- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $1,995.26 / $7,413.10
| Facility | | $363.08 | $1,995.26 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,238.72 / $4,265.80
| Facility | | $831.76 | $2,238.72 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,548.82
| Facility | | $1,230.27 | $1,230.27 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $588.84 / $1,174.90
| Professional | | $213.80 | $588.84 | $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
- $151.36 / $812.83 / $2,630.27
| Facility | | $151.36 | $812.83 | $2,630.27 |