- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,884.03 / $7,762.47
| Facility | | $1,023.29 | $2,884.03 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,511.38 / $16,218.10
| Facility | | $4,265.80 | $8,511.38 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,288.25 / $3,090.30
| Professional | | $794.33 | $1,288.25 | $3,090.30 |
- 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 |