- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,884.03 / $7,762.47
| Facility | | $1,023.29 | $2,884.03 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,365.16 / $12,302.69
| Facility | | $3,630.78 | $4,365.16 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,000.00 / $2,884.03
| Professional | | $630.96 | $1,000.00 | $2,884.03 |
- 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 / $2,398.83 / $5,128.61
| Facility | | $1,174.90 | $2,398.83 | $5,128.61 |