- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,368.80 / $8,320.00 / $31,658.54
| Facility | | $1,368.80 | $8,320.00 | $31,658.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,372.80 / $8,364.41 / $32,477.65
| Facility | | $4,372.80 | $8,364.41 | $32,477.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.32 / $1,288.58 / $4,150.68
| Professional | | $856.32 | $1,288.58 | $4,150.68 |
- 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
- $2,655.00 / $8,879.00 / $35,962.00
| Facility | | $2,655.00 | $8,879.00 | $35,962.00 |