- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,118.00 / $8,084.00 / $27,143.96
| Facility | | $4,118.00 | $8,084.00 | $27,143.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,695.00 / $11,298.00 / $18,693.00
| Professional | | $5,695.00 | $11,298.00 | $18,693.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55,249.45 / $55,249.45 / $55,249.45
| Professional | | $55,249.45 | $55,249.45 | $55,249.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,253.06 / $1,503.12 / $2,667.76
| Facility | | $1,253.06 | $1,503.12 | $2,667.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,354.00 / $3,961.00 / $10,536.00
| Facility | | $2,354.00 | $3,961.00 | $10,536.00 |