- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,187.76 / $7,762.47
| Facility | | $933.25 | $2,187.76 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $12,302.69
| Facility | | $2,089.30 | $2,754.23 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $954.99 / $2,884.03
| Professional | | $602.56 | $954.99 | $2,884.03 |
- 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
- $1,096.48 / $2,290.87 / $4,786.30
| Facility | | $1,096.48 | $2,290.87 | $4,786.30 |