- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,090.30 / $8,511.38
| Facility | | $1,096.48 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $8,511.38 / $19,054.61
| Facility | | $4,677.35 | $8,511.38 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,513.56 / $3,235.94
| Professional | | $912.01 | $1,513.56 | $3,235.94 |
- 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 / $4,365.16 / $7,585.78
| Facility | | $1,288.25 | $4,365.16 | $7,585.78 |