- 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
- $21,877.62 / $58,884.37 / $112,201.85
| Facility | | $21,877.62 | $58,884.37 | $112,201.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $7,079.46 / $19,498.45
| Professional | | $4,265.80 | $7,079.46 | $19,498.45 |
- 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 |