- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,784.65 / $2,556.00 / $5,923.00
| Facility | | $1,784.65 | $2,556.00 | $5,923.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,088.00 / $6,151.00 / $13,808.43
| Facility | | $5,088.00 | $6,151.00 | $13,808.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,806.00 / $17,045.00 / $17,152.00
| Facility | | $13,806.00 | $17,045.00 | $17,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.44 / $1,707.98 / $2,462.36
| Professional | | $23.44 | $1,707.98 | $2,462.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.00 / $2,578.00 / $6,471.00
| Facility | | $776.00 | $2,578.00 | $6,471.00 |