- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,995.26 / $7,762.47
| Facility | | $741.31 | $1,995.26 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $15,488.17
| Facility | | $2,089.30 | $2,754.23 | $15,488.17 |
- 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
- $741.31 / $1,174.90 / $3,467.37
| Professional | | $741.31 | $1,174.90 | $3,467.37 |
- 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
- $158.49 / $1,023.29 / $3,235.94
| Facility | | $158.49 | $1,023.29 | $3,235.94 |