- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $4,073.80 / $9,772.37
| Facility | | $794.33 | $4,073.80 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,786.30 / $9,772.37
| Facility | | $4,073.80 | $4,786.30 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $9,772.37 / $10,000.00
| Facility | | $5,754.40 | $9,772.37 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $776.25 / $2,041.74
| Professional | | $467.74 | $776.25 | $2,041.74 |
- 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
- $2,137.96 / $5,370.32 / $12,302.69
| Facility | | $2,137.96 | $5,370.32 | $12,302.69 |