- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,677.35 / $9,772.37
| Facility | | $1,148.15 | $4,677.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,182.57 / $35,481.34 / $67,608.30
| Facility | | $13,182.57 | $35,481.34 | $67,608.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,897.79 / $18,197.01
| Professional | | $2,398.83 | $4,897.79 | $18,197.01 |
- 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 / $2,951.21 / $7,413.10
| Facility | | $575.44 | $2,951.21 | $7,413.10 |