- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,454.71 / $7,762.47
| Facility | | $724.44 | $2,454.71 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $11,481.54
| Facility | | $4,073.80 | $4,897.79 | $11,481.54 |
- 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
- $549.54 / $870.96 / $2,290.87
| Professional | | $549.54 | $870.96 | $2,290.87 |
- 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 / $3,630.78 / $7,585.78
| Facility | | $1,513.56 | $3,630.78 | $7,585.78 |