- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,548.13 / $7,585.78
| Facility | | $1,513.56 | $3,548.13 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,073.80 / $10,232.93
| Professional | | $2,691.53 | $4,073.80 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $8,511.38 / $13,803.84
| Facility | | $4,365.16 | $8,511.38 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,715.19 / $12,589.25
| Facility | | $6,606.93 | $10,715.19 | $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
- $6,456.54 / $10,232.93 / $19,952.62
| Facility | | $6,456.54 | $10,232.93 | $19,952.62 |