- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $5,128.61 / $10,964.78
| Facility | | $1,348.96 | $5,128.61 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $20,892.96 / $40,738.03
| Facility | | $7,762.47 | $20,892.96 | $40,738.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,187.76 / $6,606.93
| Professional | | $1,348.96 | $2,187.76 | $6,606.93 |
- 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
- $575.44 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |