- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $3,715.35 / $11,220.18
| Facility | | $870.96 | $3,715.35 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $10,471.29 / $14,791.08
| Facility | | $7,079.46 | $10,471.29 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Facility | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,122.02 / $3,715.35
| Professional | | $707.95 | $1,122.02 | $3,715.35 |
- 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 / $6,025.60 / $12,882.50
| Facility | | $2,137.96 | $6,025.60 | $12,882.50 |