- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,168.69 / $9,772.37
| Facility | | $1,148.15 | $4,168.69 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $15,848.93
| Facility | | $4,168.69 | $5,128.61 | $15,848.93 |
- 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
- $758.58 / $1,202.26 / $3,890.45
| Professional | | $758.58 | $1,202.26 | $3,890.45 |
- 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 |