- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.39 / $1,696.07 / $4,845.50
| Facility | | $426.39 | $1,696.07 | $4,845.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,259.12 / $4,644.58 / $7,073.00
| Facility | | $2,259.12 | $4,644.58 | $7,073.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.00 / $875.00 / $908.00
| Facility | | $875.00 | $875.00 | $908.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.40 / $1,480.92 / $2,275.66
| Professional | | $345.40 | $1,480.92 | $2,275.66 |
- 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
- $930.00 / $3,951.00 / $6,625.00
| Facility | | $930.00 | $3,951.00 | $6,625.00 |