- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,159.00 / $2,293.41 / $5,549.00
| Facility | | $1,159.00 | $2,293.41 | $5,549.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,463.32 / $20,242.40 / $40,535.40
| Facility | | $9,463.32 | $20,242.40 | $40,535.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.86 / $2,000.59 / $5,996.18
| Professional | | $1,294.86 | $2,000.59 | $5,996.18 |
- 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
- $578.00 / $2,873.00 / $7,384.00
| Facility | | $578.00 | $2,873.00 | $7,384.00 |