- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,862.09 / $5,888.44
| Facility | | $645.65 | $1,862.09 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,570.40 / $8,511.38
| Facility | | $2,137.96 | $2,570.40 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $776.25 / $1,548.82
| Professional | | $457.09 | $776.25 | $1,548.82 |
- 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
- $1,318.26 / $3,548.13 / $6,165.95
| Facility | | $1,318.26 | $3,548.13 | $6,165.95 |