- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,265.80 / $9,772.37
| Facility | | $1,148.15 | $4,265.80 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,481.54 / $30,902.95 / $58,884.37
| Facility | | $11,481.54 | $30,902.95 | $58,884.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,715.35 / $12,589.25
| Professional | | $2,238.72 | $3,715.35 | $12,589.25 |
- 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 |