- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,630.78 / $14,125.38
| Facility | | $1,202.26 | $3,630.78 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,513.56
| Professional | | $1,202.26 | $1,202.26 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $912.01 / $3,311.31
| Professional | | $691.83 | $912.01 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,737.80 / $2,187.76
| Facility | | $1,202.26 | $1,737.80 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,479.11 / $10,964.78
| Facility | | $1,071.52 | $1,479.11 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,479.11 / $10,964.78
| Professional | | $1,071.52 | $1,479.11 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $1,202.26 / $2,454.71
| Facility | | $229.09 | $1,202.26 | $2,454.71 |