- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $6,165.95 / $25,703.96
| Facility | | $1,348.96 | $6,165.95 | $25,703.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $8,709.64 / $26,915.35
| Facility | | $6,606.93 | $8,709.64 | $26,915.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $11,748.98 / $12,882.50
| Facility | | $7,762.47 | $11,748.98 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,187.76 / $7,413.10
| Professional | | $1,318.26 | $2,187.76 | $7,413.10 |
- 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
- $2,089.30 / $5,370.32 / $12,302.69
| Facility | | $2,089.30 | $5,370.32 | $12,302.69 |