- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $2,290.87 / $7,762.47
| Facility | | $676.08 | $2,290.87 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $10,232.93 / $12,589.25
| Facility | | $4,466.84 | $10,232.93 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $9,332.54
| Facility | | $9,332.54 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $891.25 / $2,137.96
| Professional | | $549.54 | $891.25 | $2,137.96 |
- 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
- $2,570.40 / $6,309.57 / $16,982.44
| Facility | | $2,570.40 | $6,309.57 | $16,982.44 |