- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,235.94 / $8,511.38
| Facility | | $1,202.26 | $3,235.94 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $18,620.87 / $35,481.34
| Facility | | $6,918.31 | $18,620.87 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,344.23 / $8,511.38
| Professional | | $1,318.26 | $2,344.23 | $8,511.38 |
- 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 |