- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $4,466.84 / $9,772.37
| Facility | | $1,258.93 | $4,466.84 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $12,589.25 / $57,543.99
| Facility | | $9,332.54 | $12,589.25 | $57,543.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,786.30 / $12,302.69
| Professional | | $2,754.23 | $4,786.30 | $12,302.69 |
- 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
- $2,398.83 / $7,244.36 / $16,982.44
| Facility | | $2,398.83 | $7,244.36 | $16,982.44 |