- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,548.13 / $9,772.37
| Facility | | $1,023.29 | $3,548.13 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $15,135.61
| Facility | | $4,168.69 | $5,128.61 | $15,135.61 |
- 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
- $724.44 / $1,148.15 / $3,162.28
| Professional | | $724.44 | $1,148.15 | $3,162.28 |
- 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 / $2,691.53 / $5,128.61
| Facility | | $1,096.48 | $2,691.53 | $5,128.61 |