- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,548.13 / $8,912.51
| Facility | | $1,122.02 | $3,548.13 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $16,218.10
| Facility | | $4,168.69 | $5,128.61 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,230.27 / $3,630.78
| Professional | | $776.25 | $1,230.27 | $3,630.78 |
- 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 / $4,365.16 / $8,912.51
| Facility | | $1,778.28 | $4,365.16 | $8,912.51 |