- 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
- $1,230.27 / $1,995.26 / $7,585.78
| Professional | | $1,230.27 | $1,995.26 | $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
- $616.60 / $2,951.21 / $7,413.10
| Facility | | $616.60 | $2,951.21 | $7,413.10 |