- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,887.22 / $5,549.00 / $28,444.17
| Facility | | $3,887.22 | $5,549.00 | $28,444.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.20 / $1,866.40 / $2,620.00
| Professional | | $933.20 | $1,866.40 | $2,620.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $10,160.00 / $15,899.59
| Facility | | $7,221.00 | $10,160.00 | $15,899.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $7,487.00 / $11,732.00
| Facility | | $1,770.00 | $7,487.00 | $11,732.00 |