- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,466.84 / $14,125.38
| Facility | | $1,318.26 | $4,466.84 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $23,988.33 / $45,708.82
| Facility | | $8,709.64 | $23,988.33 | $45,708.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,951.21 / $8,709.64
| Professional | | $1,862.09 | $2,951.21 | $8,709.64 |
- 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 |