- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,801.89 / $9,772.37
| Facility | | $1,122.02 | $3,801.89 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $18,620.87 / $22,387.21
| Facility | | $9,549.93 | $18,620.87 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $16,982.44 / $16,982.44
| Facility | | $16,982.44 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,479.11 / $3,981.07
| Professional | | $933.25 | $1,479.11 | $3,981.07 |
- 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
- $2,570.40 / $7,943.28 / $16,982.44
| Facility | | $2,570.40 | $7,943.28 | $16,982.44 |