- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,548.13 / $8,912.51
| Facility | | $1,096.48 | $3,548.13 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $8,912.51 / $12,589.25
| Facility | | $4,786.30 | $8,912.51 | $12,589.25 |
- 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
- $691.83 / $1,230.27 / $2,951.21
| Professional | | $691.83 | $1,230.27 | $2,951.21 |
- 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
- $1,258.93 / $5,248.07 / $9,772.37
| Facility | | $1,258.93 | $5,248.07 | $9,772.37 |