- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,570.40 / $7,762.47
| Facility | | $724.44 | $2,570.40 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $10,000.00
| Facility | | $2,089.30 | $2,511.89 | $10,000.00 |
- 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
- $489.78 / $776.25 / $2,238.72
| Professional | | $489.78 | $776.25 | $2,238.72 |
- 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
- $1,096.48 / $2,290.87 / $4,786.30
| Facility | | $1,096.48 | $2,290.87 | $4,786.30 |