- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,235.94 / $9,772.37
| Facility | | $1,148.15 | $3,235.94 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $16,595.87 / $32,359.37
| Facility | | $6,165.95 | $16,595.87 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,089.30 / $6,025.60
| Professional | | $1,202.26 | $2,089.30 | $6,025.60 |
- 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 |