- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $5,623.41 / $9,772.37
| Facility | | $1,122.02 | $5,623.41 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,818.38 / $5,495.41
| Facility | | $1,047.13 | $2,818.38 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $416.87 / $1,513.56
| Professional | | $263.03 | $416.87 | $1,513.56 |
- 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
- $575.44 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |