- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $2,570.40 / $8,511.38
| Facility | | $588.84 | $2,570.40 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $10,471.29 / $13,803.84
| Facility | | $6,309.57 | $10,471.29 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $8,912.51 / $8,912.51
| Facility | | $8,912.51 | $8,912.51 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $977.24 / $2,818.38
| Professional | | $616.60 | $977.24 | $2,818.38 |
- 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
- $2,570.40 / $6,309.57 / $16,982.44
| Facility | | $2,570.40 | $6,309.57 | $16,982.44 |