- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,187.76 / $5,888.44
| Facility | | $977.24 | $2,187.76 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $13,182.57
| Facility | | $4,073.80 | $4,897.79 | $13,182.57 |
- 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
- $645.65 / $1,071.52 / $2,691.53
| Professional | | $645.65 | $1,071.52 | $2,691.53 |
- 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 |