- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,715.35 / $11,481.54
| Facility | | $1,122.02 | $3,715.35 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $11,481.54 / $21,877.62
| Facility | | $4,265.80 | $11,481.54 | $21,877.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $588.84
| Facility | | $398.11 | $398.11 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,862.09 / $4,466.84
| Professional | | $1,047.13 | $1,862.09 | $4,466.84 |
- 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
- $575.44 / $2,818.38 / $7,413.10
| Facility | | $575.44 | $2,818.38 | $7,413.10 |