- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,715.35 / $9,772.37
| Facility | | $1,122.02 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $10,964.78 / $24,547.09
| Facility | | $8,912.51 | $10,964.78 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,905.46 / $6,309.57
| Professional | | $1,202.26 | $1,905.46 | $6,309.57 |
- 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 / $7,244.36 / $16,982.44
| Facility | | $1,778.28 | $7,244.36 | $16,982.44 |