- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,073.80 / $9,772.37
| Facility | | $1,122.02 | $4,073.80 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,128.31 / $12,589.25
| Facility | | $4,466.84 | $8,128.31 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,148.15 / $2,511.89
| Professional | | $616.60 | $1,148.15 | $2,511.89 |
- 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
- $1,659.59 / $7,244.36 / $15,488.17
| Facility | | $1,659.59 | $7,244.36 | $15,488.17 |