- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,548.13 / $8,912.51
| Facility | | $1,122.02 | $3,548.13 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,495.41 / $22,387.21
| Facility | | $4,570.88 | $5,495.41 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,862.09 / $5,495.41
| Professional | | $1,148.15 | $1,862.09 | $5,495.41 |
- 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
- $1,862.09 / $4,365.16 / $9,332.54
| Facility | | $1,862.09 | $4,365.16 | $9,332.54 |