- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,884.03 / $8,317.64
| Facility | | $933.25 | $2,884.03 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $15,135.61
| Facility | | $4,168.69 | $5,128.61 | $15,135.61 |
- 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
- $707.95 / $1,148.15 / $3,388.44
| Professional | | $707.95 | $1,148.15 | $3,388.44 |
- 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 |