- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,981.07 / $11,481.54
| Facility | | $1,023.29 | $3,981.07 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $19,054.61
| Facility | | $4,168.69 | $5,128.61 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $9,772.37 / $10,000.00
| Facility | | $3,090.30 | $9,772.37 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,445.44 / $5,370.32
| Professional | | $912.01 | $1,445.44 | $5,370.32 |
- 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
- $1,778.28 / $4,365.16 / $8,912.51
| Facility | | $1,778.28 | $4,365.16 | $8,912.51 |