- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,884.03 / $7,762.47
| Facility | | $724.44 | $2,884.03 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,951.21 / $8,511.38
| Facility | | $2,454.71 | $2,951.21 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $1,819.70
| Facility | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $691.83 / $1,698.24
| Professional | | $436.52 | $691.83 | $1,698.24 |
- 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
- $1,513.56 / $3,548.13 / $6,165.95
| Facility | | $1,513.56 | $3,548.13 | $6,165.95 |