- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,715.35 / $9,772.37
| Facility | | $1,023.29 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $10,471.29 / $16,595.87
| Facility | | $8,128.31 | $10,471.29 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $3,630.78
| Professional | | $812.83 | $1,288.25 | $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 / $7,244.36 / $16,982.44
| Facility | | $1,778.28 | $7,244.36 | $16,982.44 |