- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,995.26 / $5,888.44
| Facility | | $741.31 | $1,995.26 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,778.28 / $7,413.10
| Facility | | $1,288.25 | $1,778.28 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,000.00 / $1,230.27
| Facility | | $302.00 | $1,000.00 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $794.33 / $1,995.26
| Professional | | $416.87 | $794.33 | $1,995.26 |
- 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
- $891.25 / $2,238.72 / $4,570.88
| Facility | | $891.25 | $2,238.72 | $4,570.88 |