- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,570.40 / $7,762.47
| Facility | | $1,023.29 | $2,570.40 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $15,848.93
| Facility | | $4,168.69 | $5,128.61 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,258.93 / $3,715.35
| Professional | | $776.25 | $1,258.93 | $3,715.35 |
- 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 / $7,079.46 / $14,454.40
| Facility | | $1,778.28 | $7,079.46 | $14,454.40 |