- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $3,467.37 / $9,772.37
| Facility | | $776.25 | $3,467.37 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,623.41 / $7,943.28
| Facility | | $2,290.87 | $5,623.41 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $11,220.18 / $14,125.38
| Facility | | $5,370.32 | $11,220.18 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $870.96 / $2,089.30
| Professional | | $501.19 | $870.96 | $2,089.30 |
- 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
- $1,288.25 / $3,548.13 / $7,585.78
| Facility | | $1,288.25 | $3,548.13 | $7,585.78 |