- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $6,760.83 / $15,848.93
| Facility | | $1,548.82 | $6,760.83 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $15,488.17 / $26,302.68
| Facility | | $7,244.36 | $15,488.17 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,995.26 / $7,943.28
| Professional | | $1,202.26 | $1,995.26 | $7,943.28 |
- 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
- $2,570.40 / $9,120.11 / $25,118.86
| Facility | | $2,570.40 | $9,120.11 | $25,118.86 |