- 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
- $8,317.64 / $22,387.21 / $42,657.95
| Facility | | $8,317.64 | $22,387.21 | $42,657.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,691.53 / $9,120.11
| Professional | | $1,621.81 | $2,691.53 | $9,120.11 |
- 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
- $707.95 / $2,137.96 / $4,570.88
| Facility | | $707.95 | $2,137.96 | $4,570.88 |