- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,995.26 / $5,623.41
| Facility | | $741.31 | $1,995.26 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $14,125.38
| Facility | | $2,089.30 | $2,754.23 | $14,125.38 |
- 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
- $691.83 / $1,096.48 / $2,951.21
| Professional | | $691.83 | $1,096.48 | $2,951.21 |
- 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 |