- 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
- $9,332.54 / $25,118.86 / $48,977.88
| Facility | | $9,332.54 | $25,118.86 | $48,977.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,630.78 / $14,454.40
| Professional | | $2,187.76 | $3,630.78 | $14,454.40 |
- 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 |