- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,145.63 / $2,741.05 / $5,430.00
| Facility | | $1,145.63 | $2,741.05 | $5,430.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,563.78 / $13,048.62 / $26,788.93
| Facility | | $8,563.78 | $13,048.62 | $26,788.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.00 / $8,658.56 / $9,666.24
| Facility | | $875.00 | $8,658.56 | $9,666.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.62 / $2,086.31 / $5,565.75
| Professional | | $1,413.62 | $2,086.31 | $5,565.75 |
- 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
- $1,499.00 / $3,751.00 / $6,514.00
| Facility | | $1,499.00 | $3,751.00 | $6,514.00 |