- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,570.40 / $7,762.47
| Facility | | $831.76 | $2,570.40 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,317.64 / $12,022.64
| Facility | | $4,265.80 | $8,317.64 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $588.84 / $5,623.41
| Facility | | $446.68 | $588.84 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,174.90 / $2,884.03
| Professional | | $676.08 | $1,174.90 | $2,884.03 |
- 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
- $1,445.44 / $5,370.32 / $12,302.69
| Facility | | $1,445.44 | $5,370.32 | $12,302.69 |