- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,677.35 / $8,511.38
| Facility | | $1,148.15 | $4,677.35 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $38,904.51 / $74,131.02
| Facility | | $14,454.40 | $38,904.51 | $74,131.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,570.88 / $10,715.19
| Professional | | $2,290.87 | $4,570.88 | $10,715.19 |
- 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 |