- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,677.35 / $14,125.38
| Facility | | $1,380.38 | $4,677.35 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $8,317.64 / $26,302.68
| Facility | | $3,715.35 | $8,317.64 | $26,302.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $14,125.38 / $19,054.61
| Facility | | $4,677.35 | $14,125.38 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,041.74 / $7,413.10
| Professional | | $1,288.25 | $2,041.74 | $7,413.10 |
- 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
- $1,778.28 / $7,413.10 / $15,488.17
| Facility | | $1,778.28 | $7,413.10 | $15,488.17 |