- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,801.89 / $8,511.38
| Facility | | $1,148.15 | $3,801.89 | $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
- $1,778.28 / $3,235.94 / $16,595.87
| Professional | | $1,778.28 | $3,235.94 | $16,595.87 |
- 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 |