- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,466.84 / $11,220.18
| Facility | | $1,023.29 | $4,466.84 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,128.31 / $17,378.01
| Facility | | $4,466.84 | $8,128.31 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,122.02 / $3,311.31
| Professional | | $660.69 | $1,122.02 | $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
- $2,570.40 / $6,456.54 / $14,791.08
| Facility | | $2,570.40 | $6,456.54 | $14,791.08 |