- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $2,630.27 / $7,762.47
| Facility | | $588.84 | $2,630.27 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $10,232.93 / $12,589.25
| Facility | | $4,365.16 | $10,232.93 | $12,589.25 |
- 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
- $524.81 / $912.01 / $2,137.96
| Professional | | $524.81 | $912.01 | $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
- $1,513.56 / $4,365.16 / $7,585.78
| Facility | | $1,513.56 | $4,365.16 | $7,585.78 |