- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $4,466.84 / $12,022.64
| Facility | | $1,258.93 | $4,466.84 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,379.62 / $25,703.96 / $48,977.88
| Facility | | $21,379.62 | $25,703.96 | $48,977.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,715.35 / $12,022.64
| Professional | | $2,344.23 | $3,715.35 | $12,022.64 |
- 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
- $2,089.30 / $8,128.31 / $28,840.32
| Facility | | $2,089.30 | $8,128.31 | $28,840.32 |