- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,162.28 / $8,511.38
| Facility | | $1,148.15 | $3,162.28 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $22,908.68 / $43,651.58
| Facility | | $8,511.38 | $22,908.68 | $43,651.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,754.23 / $6,918.31
| Professional | | $1,548.82 | $2,754.23 | $6,918.31 |
- 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
- $2,570.40 / $7,413.10 / $21,877.62
| Facility | | $2,570.40 | $7,413.10 | $21,877.62 |