- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,064.70 / $4,396.00 / $42,163.00
| Facility | | $1,064.70 | $4,396.00 | $42,163.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,671.00 / $4,589.00 / $6,006.00
| Facility | | $3,671.00 | $4,589.00 | $6,006.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,934.00 / $15,934.00 / $15,934.00
| Facility | | $15,934.00 | $15,934.00 | $15,934.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.64 / $1,059.15 / $1,605.08
| Professional | | $17.64 | $1,059.15 | $1,605.08 |
- 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 |