- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $5,248.07 / $15,848.93
| Facility | | $1,047.13 | $5,248.07 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $16,595.87 / $21,877.62
| Facility | | $6,760.83 | $16,595.87 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,023.29 / $3,548.13
| Professional | | $616.60 | $1,023.29 | $3,548.13 |
- 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 / $7,943.28 / $16,982.44
| Facility | | $2,570.40 | $7,943.28 | $16,982.44 |