- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,235.94 / $9,772.37
| Facility | | $1,148.15 | $3,235.94 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $15,135.61 / $29,512.09
| Facility | | $5,623.41 | $15,135.61 | $29,512.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $588.84
| Facility | | $398.11 | $398.11 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,511.89 / $8,128.31
| Professional | | $1,445.44 | $2,511.89 | $8,128.31 |
- 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
- $1,148.15 / $3,801.89 / $6,165.95
| Facility | | $1,148.15 | $3,801.89 | $6,165.95 |