- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $3,548.13 / $8,912.51
| Facility | | $616.60 | $3,548.13 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,786.30 / $7,585.78
| Facility | | $3,715.35 | $4,786.30 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $630.96 / $1,698.24
| Professional | | $363.08 | $630.96 | $1,698.24 |
- 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
- $1,096.48 / $2,691.53 / $5,128.61
| Facility | | $1,096.48 | $2,691.53 | $5,128.61 |