- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,884.03 / $8,317.64
| Facility | | $645.65 | $2,884.03 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,786.30 / $7,244.36
| Facility | | $3,548.13 | $4,786.30 | $7,244.36 |
- 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 / $602.56 / $1,445.44
| Professional | | $363.08 | $602.56 | $1,445.44 |
- 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
- $1,513.56 / $3,630.78 / $7,585.78
| Facility | | $1,513.56 | $3,630.78 | $7,585.78 |