- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,090.30 / $8,511.38
| Facility | | $1,122.02 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,182.57 / $25,118.86
| Facility | | $4,897.79 | $13,182.57 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,584.89 / $4,677.35
| Professional | | $954.99 | $1,584.89 | $4,677.35 |
- 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 / $7,413.10 / $21,877.62
| Facility | | $2,570.40 | $7,413.10 | $21,877.62 |