- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $3,715.35 / $9,772.37
| Facility | | $1,071.52 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,165.95 / $20,417.38
| Facility | | $5,011.87 | $6,165.95 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,412.54 / $4,365.16
| Professional | | $758.58 | $1,412.54 | $4,365.16 |
- 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
- $1,584.89 / $4,365.16 / $9,332.54
| Facility | | $1,584.89 | $4,365.16 | $9,332.54 |