- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,677.35 / $9,332.54
| Facility | | $1,148.15 | $4,677.35 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $31,622.78 / $61,659.50
| Facility | | $11,748.98 | $31,622.78 | $61,659.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,265.80 / $16,595.87
| Professional | | $2,238.72 | $4,265.80 | $16,595.87 |
- 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 |