- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,388.44 / $8,511.38
| Facility | | $1,148.15 | $3,388.44 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $20,417.38 / $38,904.51
| Facility | | $7,585.78 | $20,417.38 | $38,904.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,019.95 / $9,772.37
| Professional | | $1,621.81 | $3,019.95 | $9,772.37 |
- 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 |