- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,786.30 / $9,772.37
| Facility | | $1,202.26 | $4,786.30 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $22,908.68 / $22,908.68
| Professional | | $2,089.30 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $16,595.87 / $19,952.62
| Facility | | $11,748.98 | $16,595.87 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $199.53 / $346.74
| Professional | | $120.23 | $199.53 | $346.74 |
- 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 |