- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,090.30 / $8,511.38
| Facility | | $1,202.26 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $21,379.62 / $41,686.94
| Facility | | $7,943.28 | $21,379.62 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,818.38 / $7,585.78
| Professional | | $1,737.80 | $2,818.38 | $7,585.78 |
- 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
- $2,570.40 / $7,244.36 / $21,877.62
| Facility | | $2,570.40 | $7,244.36 | $21,877.62 |