- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,235.94 / $9,772.37
| Facility | | $1,148.15 | $3,235.94 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $28,183.83 / $54,954.09
| Facility | | $10,471.29 | $28,183.83 | $54,954.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,168.69 / $14,454.40
| Professional | | $2,398.83 | $4,168.69 | $14,454.40 |
- 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
- $575.44 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |