- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,466.84 / $14,125.38
| Facility | | $1,148.15 | $4,466.84 | $14,125.38 |
- 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
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,412.54 / $4,073.80
| Professional | | $870.96 | $1,412.54 | $4,073.80 |
- 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
- $1,778.28 / $4,365.16 / $8,912.51
| Facility | | $1,778.28 | $4,365.16 | $8,912.51 |