- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $3,090.30 / $9,772.37
| Facility | | $645.65 | $3,090.30 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $10,471.29 / $14,125.38
| Facility | | $3,388.44 | $10,471.29 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $12,589.25 / $28,840.32
| Facility | | $9,120.11 | $12,589.25 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $575.44 / $1,479.11
| Professional | | $346.74 | $575.44 | $1,479.11 |
- 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 / $9,120.11 / $28,840.32
| Facility | | $2,570.40 | $9,120.11 | $28,840.32 |