- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,630.27 / $6,606.93
| Facility | | $1,000.00 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,128.61 / $6,606.93
| Professional | | $3,162.28 | $5,128.61 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,309.57 / $10,471.29
| Facility | | $4,073.80 | $6,309.57 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.13 / $602.56 / $1,659.59
| Facility | | $89.13 | $602.56 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $616.60 / $1,659.59
| Facility | | $138.04 | $616.60 | $1,659.59 |