- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,570.40 / $7,762.47
| Facility | | $1,202.26 | $2,570.40 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,466.84 / $26,915.35
| Facility | | $3,548.13 | $4,466.84 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,290.87 / $5,128.61
| Professional | | $1,318.26 | $2,290.87 | $5,128.61 |
- 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 / $3,548.13 / $7,079.46
| Facility | | $1,288.25 | $3,548.13 | $7,079.46 |