- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $4,265.80 / $14,125.38
| Facility | | $1,174.90 | $4,265.80 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,128.31 / $16,595.87
| Facility | | $4,466.84 | $8,128.31 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,548.82 / $5,370.32
| Professional | | $933.25 | $1,548.82 | $5,370.32 |
- 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 |