- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.61 / $1,472.87 / $5,196.59
| Facility | | $389.61 | $1,472.87 | $5,196.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,159.01 / $3,921.98 / $5,390.53
| Facility | | $2,159.01 | $3,921.98 | $5,390.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $620.00 / $620.00 / $643.00
| Facility | | $620.00 | $620.00 | $643.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.27 / $567.15 / $1,195.81
| Professional | | $284.27 | $567.15 | $1,195.81 |
- 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
- $1,600.00 / $3,951.00 / $6,625.00
| Facility | | $1,600.00 | $3,951.00 | $6,625.00 |