- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,715.35 / $8,511.38
| Facility | | $1,148.15 | $3,715.35 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $26,302.68 / $51,286.14
| Facility | | $9,772.37 | $26,302.68 | $51,286.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,235.94 / $9,772.37
| Professional | | $1,949.84 | $3,235.94 | $9,772.37 |
- 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 |