- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,715.35 / $9,772.37
| Facility | | $1,202.26 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,182.57 / $25,703.96
| Facility | | $4,897.79 | $13,182.57 | $25,703.96 |
- 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
- $1,122.02 / $2,137.96 / $4,897.79
| Professional | | $1,122.02 | $2,137.96 | $4,897.79 |
- 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 |