- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $2,187.76 / $7,762.47
| Facility | | $741.31 | $2,187.76 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,786.30 / $8,511.38
| Facility | | $4,073.80 | $4,786.30 | $8,511.38 |
- 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
- $436.52 / $741.31 / $2,041.74
| Professional | | $436.52 | $741.31 | $2,041.74 |
- 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 |