- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,168.69 / $9,772.37
| Facility | | $1,148.15 | $4,168.69 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $18,620.87 / $22,387.21
| Facility | | $9,332.54 | $18,620.87 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,445.44 / $4,265.80
| Professional | | $912.01 | $1,445.44 | $4,265.80 |
- 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
- $2,570.40 / $7,943.28 / $16,982.44
| Facility | | $2,570.40 | $7,943.28 | $16,982.44 |