- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,466.84 / $9,772.37
| Facility | | $1,023.29 | $4,466.84 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,981.07 / $9,549.93
| Facility | | $2,344.23 | $3,981.07 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $724.44 / $2,691.53
| Facility | | $575.44 | $724.44 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,023.29 / $2,511.89
| Professional | | $575.44 | $1,023.29 | $2,511.89 |
- 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
- $1,584.89 / $4,365.16 / $8,912.51
| Facility | | $1,584.89 | $4,365.16 | $8,912.51 |