- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,467.37 / $9,772.37
| Facility | | $1,258.93 | $3,467.37 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $10,964.78 / $28,183.83
| Facility | | $9,120.11 | $10,964.78 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,187.76 / $6,165.95
| Professional | | $1,380.38 | $2,187.76 | $6,165.95 |
- 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
- $1,778.28 / $7,244.36 / $16,982.44
| Facility | | $1,778.28 | $7,244.36 | $16,982.44 |