- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,786.30 / $11,481.54
| Facility | | $1,023.29 | $4,786.30 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,630.78 / $16,218.10
| Facility | | $2,951.21 | $3,630.78 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,888.44 / $7,762.47
| Facility | | $4,365.16 | $5,888.44 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,148.15 / $3,311.31
| Professional | | $616.60 | $1,148.15 | $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
- $1,174.90 / $3,388.44 / $5,754.40
| Facility | | $1,174.90 | $3,388.44 | $5,754.40 |