- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,090.30 / $7,762.47
| Facility | | $1,202.26 | $3,090.30 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $25,703.96 / $48,977.88
| Facility | | $9,549.93 | $25,703.96 | $48,977.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,630.78 / $14,791.08
| Professional | | $2,238.72 | $3,630.78 | $14,791.08 |
- 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
- $1,288.25 / $3,388.44 / $6,165.95
| Facility | | $1,288.25 | $3,388.44 | $6,165.95 |