- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,090.30 / $8,511.38
| Facility | | $1,000.00 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $11,481.54 / $21,877.62
| Facility | | $4,265.80 | $11,481.54 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,445.44 / $4,168.69
| Professional | | $851.14 | $1,445.44 | $4,168.69 |
- 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 |