- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $3,548.13 / $8,511.38
| Facility | | $724.44 | $3,548.13 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $8,912.51
| Facility | | $2,089.30 | $2,511.89 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $707.95 / $1,995.26
| Professional | | $426.58 | $707.95 | $1,995.26 |
- 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 / $2,290.87 / $4,786.30
| Facility | | $1,096.48 | $2,290.87 | $4,786.30 |