- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,265.80 / $14,125.38
| Facility | | $1,023.29 | $4,265.80 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,897.79 / $13,489.63
| Facility | | $3,311.31 | $4,897.79 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,047.13 / $2,884.03
| Professional | | $676.08 | $1,047.13 | $2,884.03 |
- 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
- $1,288.25 / $3,548.13 / $7,585.78
| Facility | | $1,288.25 | $3,548.13 | $7,585.78 |