- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $38,904.51 / $75,857.76
| Facility | | $14,454.40 | $38,904.51 | $75,857.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $7,079.46 / $8,912.51
| Professional | | $5,011.87 | $7,079.46 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $199.53 / $346.74
| Professional | | $100.00 | $199.53 | $346.74 |
- 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
- $2,570.40 / $3,981.07 / $6,456.54
| Facility | | $2,570.40 | $3,981.07 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,548.13 / $5,011.87
| Professional | | $3,388.44 | $3,548.13 | $5,011.87 |