- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,370.32 / $16,218.10
| Facility | | $1,202.26 | $5,370.32 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $16,218.10 / $21,877.62
| Facility | | $5,370.32 | $16,218.10 | $21,877.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,606.93 / $15,135.61
| Facility | | $4,897.79 | $6,606.93 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $831.76 / $4,466.84
| Professional | | $501.19 | $831.76 | $4,466.84 |
- 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
- $3,311.31 / $9,772.37 / $25,703.96
| Facility | | $3,311.31 | $9,772.37 | $25,703.96 |