- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $3,548.13 / $8,912.51
| Facility | | $707.95 | $3,548.13 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,265.80 / $9,120.11
| Facility | | $1,698.24 | $4,265.80 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $5,623.41
| Facility | | $1,230.27 | $1,230.27 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $1,122.02 / $1,905.46
| Professional | | $446.68 | $1,122.02 | $1,905.46 |
- 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
- $3,388.44 / $6,025.60 / $14,454.40
| Facility | | $3,388.44 | $6,025.60 | $14,454.40 |