- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,128.61 / $12,589.25
| Facility | | $1,202.26 | $5,128.61 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $18,620.87
| Facility | | $4,168.69 | $5,128.61 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,380.38 / $4,677.35
| Professional | | $870.96 | $1,380.38 | $4,677.35 |
- 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
- $2,137.96 / $5,370.32 / $12,302.69
| Facility | | $2,137.96 | $5,370.32 | $12,302.69 |