- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $4,466.84 / $11,481.54
| Facility | | $1,071.52 | $4,466.84 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $9,332.54 / $16,218.10
| Facility | | $2,818.38 | $9,332.54 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,479.11 / $3,090.30
| Professional | | $912.01 | $1,479.11 | $3,090.30 |
- 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
- $1,778.28 / $7,244.36 / $16,982.44
| Facility | | $1,778.28 | $7,244.36 | $16,982.44 |