- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,311.31 / $7,762.47
| Facility | | $1,023.29 | $3,311.31 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $12,589.25
| Facility | | $4,073.80 | $4,897.79 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,071.52 / $3,090.30
| Professional | | $616.60 | $1,071.52 | $3,090.30 |
- 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 / $4,365.16 / $8,912.51
| Facility | | $1,778.28 | $4,365.16 | $8,912.51 |