- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,858.49 / $4,396.00 / $10,300.00
| Facility | | $1,858.49 | $4,396.00 | $10,300.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,996.00 / $8,455.00 / $16,907.36
| Facility | | $6,996.00 | $8,455.00 | $16,907.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,182.00 / $15,182.00 / $15,182.00
| Facility | | $15,182.00 | $15,182.00 | $15,182.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.00 / $1,839.63 / $2,926.68
| Professional | | $32.00 | $1,839.63 | $2,926.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,061.00 / $2,606.00 / $6,471.00
| Facility | | $1,061.00 | $2,606.00 | $6,471.00 |