- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,011.87 / $14,454.40
| Facility | | $1,202.26 | $5,011.87 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $18,620.87 / $23,988.33
| Facility | | $10,964.78 | $18,620.87 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,659.59 / $5,011.87
| Professional | | $1,071.52 | $1,659.59 | $5,011.87 |
- 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 |