- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,715.35 / $9,772.37
| Facility | | $1,148.15 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $10,964.78 / $27,542.29
| Facility | | $9,120.11 | $10,964.78 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,089.30 / $6,606.93
| Professional | | $1,318.26 | $2,089.30 | $6,606.93 |
- 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
- $707.95 / $5,370.32 / $12,302.69
| Facility | | $707.95 | $5,370.32 | $12,302.69 |