- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,159.00 / $5,389.00 / $9,371.78
| Facility | | $1,159.00 | $5,389.00 | $9,371.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31,207.34 / $66,753.67 / $133,674.24
| Facility | | $31,207.34 | $66,753.67 | $133,674.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,678.85 / $7,933.76 / $31,118.24
| Professional | | $4,678.85 | $7,933.76 | $31,118.24 |
- 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
- $578.00 / $2,873.00 / $7,384.00
| Facility | | $578.00 | $2,873.00 | $7,384.00 |