- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,137.96 / $7,762.47
| Facility | | $1,023.29 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $22,387.21
| Facility | | $4,168.69 | $5,128.61 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,698.24 / $4,570.88
| Professional | | $1,071.52 | $1,698.24 | $4,570.88 |
- 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
- $707.95 / $5,370.32 / $12,302.69
| Facility | | $707.95 | $5,370.32 | $12,302.69 |