- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,365.16 / $4,570.88
| Facility | | $2,570.40 | $4,365.16 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $28,840.32 / $56,234.13
| Facility | | $10,715.19 | $28,840.32 | $56,234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,265.80 / $7,079.46
| Professional | | $2,454.71 | $4,265.80 | $7,079.46 |
- 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
- $616.60 / $2,884.03 / $7,413.10
| Facility | | $616.60 | $2,884.03 | $7,413.10 |