- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,265.80 / $11,220.18
| Facility | | $1,023.29 | $4,265.80 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $15,488.17
| Facility | | $4,168.69 | $5,128.61 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,174.90 / $3,467.37
| Professional | | $741.31 | $1,174.90 | $3,467.37 |
- 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
- $1,096.48 / $2,691.53 / $5,128.61
| Facility | | $1,096.48 | $2,691.53 | $5,128.61 |