- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $5,370.32 / $10,715.19
| Facility | | $794.33 | $5,370.32 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,265.80 / $9,120.11
| Facility | | $1,819.70 | $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
- $478.63 / $1,174.90 / $1,949.84
| Professional | | $478.63 | $1,174.90 | $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
- $3,388.44 / $6,025.60 / $14,454.40
| Facility | | $3,388.44 | $6,025.60 | $14,454.40 |