- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,890.45 / $11,481.54
| Facility | | $1,258.93 | $3,890.45 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $19,054.61 / $39,810.72
| Facility | | $15,848.93 | $19,054.61 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,951.21 / $7,244.36
| Professional | | $1,862.09 | $2,951.21 | $7,244.36 |
- 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
- $1,288.25 / $6,309.57 / $16,982.44
| Facility | | $1,288.25 | $6,309.57 | $16,982.44 |