- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,090.30 / $9,332.54
| Facility | | $1,202.26 | $3,090.30 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,011.87 / $40,738.03
| Facility | | $3,715.35 | $5,011.87 | $40,738.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,467.37 / $10,232.93
| Professional | | $1,995.26 | $3,467.37 | $10,232.93 |
- 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
- $1,412.54 / $3,548.13 / $6,918.31
| Facility | | $1,412.54 | $3,548.13 | $6,918.31 |