- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,466.84 / $14,125.38
| Facility | | $1,148.15 | $4,466.84 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,128.31 / $16,218.10
| Facility | | $4,466.84 | $8,128.31 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $954.99 / $2,187.76
| Professional | | $575.44 | $954.99 | $2,187.76 |
- 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 |