- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,818.38 / $7,943.28
| Facility | | $1,023.29 | $2,818.38 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,466.84 / $14,125.38
| Facility | | $3,715.35 | $4,466.84 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,047.13 / $2,344.23
| Professional | | $616.60 | $1,047.13 | $2,344.23 |
- 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
- $1,096.48 / $2,398.83 / $5,128.61
| Facility | | $1,096.48 | $2,398.83 | $5,128.61 |