- 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
- $7,244.36 / $19,498.45 / $37,153.52
| Facility | | $7,244.36 | $19,498.45 | $37,153.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,398.83 / $7,943.28
| Professional | | $1,412.54 | $2,398.83 | $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
- $575.44 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |