- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,884.03 / $7,762.47
| Facility | | $1,023.29 | $2,884.03 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,466.84 / $13,489.63
| Facility | | $3,715.35 | $4,466.84 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,122.02 / $3,311.31
| Professional | | $691.83 | $1,122.02 | $3,311.31 |
- 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
- $1,584.89 / $3,630.78 / $7,079.46
| Facility | | $1,584.89 | $3,630.78 | $7,079.46 |