- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $3,890.45 / $8,912.51
| Facility | | $407.38 | $3,890.45 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,265.80 / $5,754.40
| Facility | | $2,089.30 | $4,265.80 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $724.44
| Facility | | $575.44 | $575.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $416.87 / $1,148.15
| Professional | | $245.47 | $416.87 | $1,148.15 |
- 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
- $1,023.29 / $3,467.37 / $7,585.78
| Facility | | $1,023.29 | $3,467.37 | $7,585.78 |