- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $4,677.35 / $11,481.54
| Facility | | $1,258.93 | $4,677.35 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,379.62 / $26,302.68 / $56,234.13
| Facility | | $21,379.62 | $26,302.68 | $56,234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,265.80 / $12,882.50
| Professional | | $2,691.53 | $4,265.80 | $12,882.50 |
- 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
- $2,398.83 / $8,128.31 / $28,840.32
| Facility | | $2,398.83 | $8,128.31 | $28,840.32 |