- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,715.35 / $9,772.37
| Facility | | $1,122.02 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $18,620.87 / $25,703.96
| Facility | | $11,748.98 | $18,620.87 | $25,703.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,378.01 / $17,378.01 / $17,378.01
| Facility | | $17,378.01 | $17,378.01 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,862.09 / $5,888.44
| Professional | | $1,174.90 | $1,862.09 | $5,888.44 |
- 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
- $2,570.40 / $7,943.28 / $16,982.44
| Facility | | $2,570.40 | $7,943.28 | $16,982.44 |