- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,187.76 / $5,888.44
| Facility | | $794.33 | $2,187.76 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,786.30 / $7,079.46
| Facility | | $2,089.30 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,288.25 / $2,691.53
| Facility | | $398.11 | $1,288.25 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $794.33 / $2,187.76
| Professional | | $457.09 | $794.33 | $2,187.76 |
- 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 / $3,548.13 / $7,585.78
| Facility | | $1,096.48 | $3,548.13 | $7,585.78 |