- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,548.13 / $8,912.51
| Facility | | $1,047.13 | $3,548.13 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $10,964.78 / $22,908.68
| Facility | | $8,912.51 | $10,964.78 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Facility | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,737.80 / $4,265.80
| Professional | | $1,096.48 | $1,737.80 | $4,265.80 |
- 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 / $5,495.41 / $9,772.37
| Facility | | $1,778.28 | $5,495.41 | $9,772.37 |