- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,884.03 / $7,762.47
| Facility | | $794.33 | $2,884.03 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $10,232.93 / $12,589.25
| Facility | | $4,786.30 | $10,232.93 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Facility | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $758.58 / $2,951.21
| Professional | | $467.74 | $758.58 | $2,951.21 |
- 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
- $1,778.28 / $5,495.41 / $9,772.37
| Facility | | $1,778.28 | $5,495.41 | $9,772.37 |