- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,715.35 / $9,772.37
| Facility | | $1,258.93 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $18,620.87 / $33,113.11
| Facility | | $15,848.93 | $18,620.87 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,511.89 / $6,606.93
| Professional | | $1,584.89 | $2,511.89 | $6,606.93 |
- 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 |