- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,041.74 / $5,888.44
| Facility | | $724.44 | $2,041.74 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,981.07 / $10,000.00
| Facility | | $2,454.71 | $3,981.07 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,288.25 / $2,398.83
| Facility | | $398.11 | $1,288.25 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,071.52 / $1,905.46
| Professional | | $537.03 | $1,071.52 | $1,905.46 |
- 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 / $2,290.87 / $5,128.61
| Facility | | $891.25 | $2,290.87 | $5,128.61 |