- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,090.30 / $9,772.37
| Facility | | $1,148.15 | $3,090.30 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $17,782.79 / $33,884.42
| Facility | | $6,606.93 | $17,782.79 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,187.76 / $6,165.95
| Professional | | $1,318.26 | $2,187.76 | $6,165.95 |
- 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 |