- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $1,380.38 / $5,623.41
| Facility | | $257.04 | $1,380.38 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,380.38 / $2,691.53
| Facility | | $512.86 | $1,380.38 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $13,182.57 / $13,489.63
| Facility | | $7,413.10 | $13,182.57 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $1,000.00 / $2,238.72
| Professional | | $162.18 | $1,000.00 | $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
- $158.49 / $891.25 / $3,388.44
| Facility | | $158.49 | $891.25 | $3,388.44 |