- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,548.13 / $8,912.51
| Facility | | $1,096.48 | $3,548.13 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $8,511.38 / $21,379.62
| Facility | | $5,370.32 | $8,511.38 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,778.28 / $5,128.61
| Professional | | $1,047.13 | $1,778.28 | $5,128.61 |
- 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 |