- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,090.30 / $12,882.50
| Facility | | $1,122.02 | $3,090.30 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $10,715.19 / $21,877.62
| Facility | | $8,912.51 | $10,715.19 | $21,877.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Facility | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,659.59 / $3,981.07
| Professional | | $954.99 | $1,659.59 | $3,981.07 |
- 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 / $6,309.57 / $16,982.44
| Facility | | $2,570.40 | $6,309.57 | $16,982.44 |