- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $2,089.30 / $5,888.44
| Facility | | $562.34 | $2,089.30 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $8,511.38
| Facility | | $2,089.30 | $2,511.89 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $660.69 / $2,344.23
| Professional | | $416.87 | $660.69 | $2,344.23 |
- 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 |