- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,548.13 / $8,912.51
| Facility | | $1,023.29 | $3,548.13 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,677.35 / $13,182.57
| Facility | | $3,235.94 | $4,677.35 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,230.27 / $4,897.79
| Professional | | $741.31 | $1,230.27 | $4,897.79 |
- 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
- $1,698.24 / $4,365.16 / $8,912.51
| Facility | | $1,698.24 | $4,365.16 | $8,912.51 |