- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,248.07 / $15,135.61
| Facility | | $1,148.15 | $5,248.07 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $9,549.93 / $15,848.93
| Facility | | $4,073.80 | $9,549.93 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $11,220.18 / $14,125.38
| Facility | | $5,370.32 | $11,220.18 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,548.82 / $3,801.89
| Professional | | $912.01 | $1,548.82 | $3,801.89 |
- 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
- $2,089.30 / $5,495.41 / $12,302.69
| Facility | | $2,089.30 | $5,495.41 | $12,302.69 |