- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,168.69 / $9,772.37
| Facility | | $1,148.15 | $4,168.69 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,791.08 / $39,810.72 / $75,857.76
| Facility | | $14,791.08 | $39,810.72 | $75,857.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,754.40 / $19,952.62
| Professional | | $3,388.44 | $5,754.40 | $19,952.62 |
- 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 |