- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,344.23 / $7,762.47
| Facility | | $794.33 | $2,344.23 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,412.54 / $5,623.41
| Professional | | $1,380.38 | $1,412.54 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $338.84 / $407.38
| Facility | | $302.00 | $338.84 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $199.53 / $346.74
| Professional | | $120.23 | $199.53 | $346.74 |
- 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
- $158.49 / $724.44 / $2,187.76
| Facility | | $158.49 | $724.44 | $2,187.76 |