- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $7,762.47 / $19,952.62
| Facility | | $1,318.26 | $7,762.47 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $8,511.38 / $19,952.62
| Facility | | $4,897.79 | $8,511.38 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $11,748.98 / $12,882.50
| Facility | | $7,762.47 | $11,748.98 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,621.81 / $5,128.61
| Professional | | $977.24 | $1,621.81 | $5,128.61 |
- 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
- $2,089.30 / $5,370.32 / $12,302.69
| Facility | | $2,089.30 | $5,370.32 | $12,302.69 |