- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,168.69 / $11,220.18
| Facility | | $1,230.27 | $4,168.69 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $10,964.78 / $26,302.68
| Facility | | $9,120.11 | $10,964.78 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,041.74 / $5,248.07
| Professional | | $1,288.25 | $2,041.74 | $5,248.07 |
- 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
- $2,089.30 / $5,370.32 / $12,302.69
| Facility | | $2,089.30 | $5,370.32 | $12,302.69 |