- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,570.40 / $5,888.44
| Facility | | $758.58 | $2,570.40 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $8,317.64 / $10,471.29
| Facility | | $3,715.35 | $8,317.64 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,511.89 / $8,317.64
| Facility | | $398.11 | $2,511.89 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $707.95 / $1,949.84
| Professional | | $416.87 | $707.95 | $1,949.84 |
- 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
- $1,096.48 / $4,265.80 / $7,585.78
| Facility | | $1,096.48 | $4,265.80 | $7,585.78 |