- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,187.76 / $5,888.44
| Facility | | $977.24 | $2,187.76 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $10,471.29 / $13,803.84
| Facility | | $6,456.54 | $10,471.29 | $13,803.84 |
- 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
- $645.65 / $1,122.02 / $3,467.37
| Professional | | $645.65 | $1,122.02 | $3,467.37 |
- 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 / $4,365.16 / $7,585.78
| Facility | | $1,513.56 | $4,365.16 | $7,585.78 |