- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $5,128.61 / $15,135.61
| Facility | | $1,258.93 | $5,128.61 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $6,456.54 / $26,302.68
| Facility | | $5,370.32 | $6,456.54 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,862.09 / $6,025.60
| Professional | | $1,000.00 | $1,862.09 | $6,025.60 |
- 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 |