- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,801.89 / $8,511.38
| Facility | | $1,148.15 | $3,801.89 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $27,542.29 / $53,703.18
| Facility | | $10,232.93 | $27,542.29 | $53,703.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,548.13 / $11,220.18
| Professional | | $2,238.72 | $3,548.13 | $11,220.18 |
- 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 / $7,244.36 / $21,877.62
| Facility | | $2,570.40 | $7,244.36 | $21,877.62 |