- 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 / $18,620.87 / $35,481.34
| Facility | | $15,848.93 | $18,620.87 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,691.53 / $8,317.64
| Professional | | $1,698.24 | $2,691.53 | $8,317.64 |
- 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 |