- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $3,235.94 / $10,471.29
| Facility | | $977.24 | $3,235.94 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $10,471.29 / $13,489.63
| Facility | | $6,309.57 | $10,471.29 | $13,489.63 |
- 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
- $741.31 / $1,174.90 / $2,691.53
| Professional | | $741.31 | $1,174.90 | $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 / $4,365.16 / $7,585.78
| Facility | | $1,513.56 | $4,365.16 | $7,585.78 |