- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $4,265.80 / $12,882.50
| Facility | | $1,174.90 | $4,265.80 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $15,488.17 / $27,542.29
| Facility | | $7,244.36 | $15,488.17 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,949.84 / $4,265.80
| Professional | | $1,174.90 | $1,949.84 | $4,265.80 |
- 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
- $3,311.31 / $9,120.11 / $25,118.86
| Facility | | $3,311.31 | $9,120.11 | $25,118.86 |