- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $2,187.76 / $6,456.54
| Facility | | $371.54 | $2,187.76 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,818.38 / $4,265.80
| Facility | | $2,137.96 | $2,818.38 | $4,265.80 |
- 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
- $223.87 / $346.74 / $891.25
| Professional | | $223.87 | $346.74 | $891.25 |
- 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 |