- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,235.94 / $8,511.38
| Facility | | $1,148.15 | $3,235.94 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $19,498.45 / $38,018.94
| Facility | | $7,244.36 | $19,498.45 | $38,018.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,754.23 / $7,244.36
| Professional | | $1,659.59 | $2,754.23 | $7,244.36 |
- 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 |