- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,884.03 / $9,332.54
| Facility | | $831.76 | $2,884.03 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $10,964.78
| Facility | | $4,073.80 | $4,897.79 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $9,772.37 / $10,000.00
| Facility | | $5,754.40 | $9,772.37 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $870.96 / $3,162.28
| Professional | | $549.54 | $870.96 | $3,162.28 |
- 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 |