- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,466.84 / $8,511.38
| Facility | | $1,148.15 | $4,466.84 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $34,673.69 / $66,069.34
| Facility | | $12,882.50 | $34,673.69 | $66,069.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,365.16 / $12,882.50
| Professional | | $2,454.71 | $4,365.16 | $12,882.50 |
- 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 |