- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,072.71 / $2,472.00 / $5,923.00
| Facility | | $2,072.71 | $2,472.00 | $5,923.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,671.00 / $5,123.00 / $7,802.00
| Facility | | $3,671.00 | $5,123.00 | $7,802.00 |
- 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
- $27.68 / $2,030.68 / $2,928.54
| Professional | | $27.68 | $2,030.68 | $2,928.54 |
- 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 |