- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $3,090.30 / $9,772.37
| Facility | | $1,071.52 | $3,090.30 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $12,589.25 / $24,547.09
| Facility | | $4,677.35 | $12,589.25 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,548.82 / $4,786.30
| Professional | | $912.01 | $1,548.82 | $4,786.30 |
- 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 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |