- 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
- $3,630.78 / $4,677.35 / $14,791.08
| Facility | | $3,630.78 | $4,677.35 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,318.26 / $2,454.71
| Professional | | $512.86 | $1,318.26 | $2,454.71 |
- 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
- $1,698.24 / $4,365.16 / $8,912.51
| Facility | | $1,698.24 | $4,365.16 | $8,912.51 |