- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,511.89 / $8,317.64
| Facility | | $812.83 | $2,511.89 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,471.29 / $14,125.38
| Facility | | $6,606.93 | $10,471.29 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $9,549.93 / $9,549.93
| Facility | | $9,549.93 | $9,549.93 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $1,000.00 / $2,089.30
| Professional | | $346.74 | $1,000.00 | $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
- $1,778.28 / $5,495.41 / $9,772.37
| Facility | | $1,778.28 | $5,495.41 | $9,772.37 |