- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,862.09 / $5,888.44
| Facility | | $870.96 | $1,862.09 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $10,471.29 / $14,791.08
| Facility | | $7,244.36 | $10,471.29 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $9,772.37
| Facility | | $9,772.37 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,258.93 / $3,162.28
| Professional | | $776.25 | $1,258.93 | $3,162.28 |
- 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 |