- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $2,089.30 / $5,888.44
| Facility | | $501.19 | $2,089.30 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,951.21 / $6,025.60
| Facility | | $2,398.83 | $2,951.21 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $1,819.70
| Facility | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $489.78 / $2,137.96
| Professional | | $316.23 | $489.78 | $2,137.96 |
- 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
- $1,513.56 / $3,548.13 / $6,165.95
| Facility | | $1,513.56 | $3,548.13 | $6,165.95 |