- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,570.88 / $11,220.18
| Facility | | $1,023.29 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,244.36 / $15,135.61
| Facility | | $3,801.89 | $7,244.36 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,258.93 / $3,162.28
| Professional | | $724.44 | $1,258.93 | $3,162.28 |
- 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
- $1,698.24 / $4,365.16 / $9,772.37
| Facility | | $1,698.24 | $4,365.16 | $9,772.37 |