- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $1,862.09 / $5,888.44
| Facility | | $446.68 | $1,862.09 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,786.30 / $6,165.95
| Facility | | $2,630.27 | $4,786.30 | $6,165.95 |
- 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
- $346.74 / $724.44 / $1,258.93
| Professional | | $346.74 | $724.44 | $1,258.93 |
- 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 |