- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,090.30 / $8,511.38
| Facility | | $1,096.48 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $12,882.50 / $24,547.09
| Facility | | $4,786.30 | $12,882.50 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,621.81 / $4,466.84
| Professional | | $912.01 | $1,621.81 | $4,466.84 |
- 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
- $575.44 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |