- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,570.40 / $7,762.47
| Facility | | $1,023.29 | $2,570.40 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,466.84 / $15,135.61
| Facility | | $3,715.35 | $4,466.84 | $15,135.61 |
- 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
- $724.44 / $1,288.25 / $3,311.31
| Professional | | $724.44 | $1,288.25 | $3,311.31 |
- 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
- $1,412.54 / $3,548.13 / $6,918.31
| Facility | | $1,412.54 | $3,548.13 | $6,918.31 |