- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,548.13 / $8,511.38
| Facility | | $1,148.15 | $3,548.13 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $25,703.96 / $48,977.88
| Facility | | $9,549.93 | $25,703.96 | $48,977.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,090.30 / $8,128.31
| Professional | | $1,862.09 | $3,090.30 | $8,128.31 |
- 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 |