- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,090.30 / $8,511.38
| Facility | | $1,148.15 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $15,135.61 / $28,840.32
| Facility | | $5,623.41 | $15,135.61 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,862.09 / $4,786.30
| Professional | | $1,174.90 | $1,862.09 | $4,786.30 |
- 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
- $1,584.89 / $4,265.80 / $8,128.31
| Facility | | $1,584.89 | $4,265.80 | $8,128.31 |