- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,128.61 / $10,471.29
| Facility | | $1,148.15 | $5,128.61 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,511.38 / $17,378.01
| Facility | | $4,265.80 | $8,511.38 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,479.11 / $5,011.87
| Professional | | $933.25 | $1,479.11 | $5,011.87 |
- 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
- $2,089.30 / $5,370.32 / $12,302.69
| Facility | | $2,089.30 | $5,370.32 | $12,302.69 |