- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,677.35 / $9,120.11
| Facility | | $1,148.15 | $4,677.35 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,182.57 / $36,307.81 / $69,183.10
| Facility | | $13,182.57 | $36,307.81 | $69,183.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,466.84 / $13,803.84
| Professional | | $2,691.53 | $4,466.84 | $13,803.84 |
- 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 |