- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,981.07 / $11,481.54
| Facility | | $1,288.25 | $3,981.07 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $15,488.17 / $30,199.52
| Facility | | $7,413.10 | $15,488.17 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,089.30 / $5,495.41
| Professional | | $1,288.25 | $2,089.30 | $5,495.41 |
- 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 / $7,943.28 / $16,982.44
| Facility | | $2,570.40 | $7,943.28 | $16,982.44 |