- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,715.35 / $11,481.54
| Facility | | $1,122.02 | $3,715.35 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,128.31 / $15,135.61
| Facility | | $4,466.84 | $8,128.31 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,412.54 / $4,466.84
| Professional | | $851.14 | $1,412.54 | $4,466.84 |
- 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
- $2,570.40 / $6,456.54 / $14,791.08
| Facility | | $2,570.40 | $6,456.54 | $14,791.08 |