- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,548.13 / $9,772.37
| Facility | | $1,122.02 | $3,548.13 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $8,128.31 / $20,892.96
| Facility | | $5,248.07 | $8,128.31 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,258.93 / $3,235.94
| Professional | | $794.33 | $1,258.93 | $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
- $2,570.40 / $6,456.54 / $14,791.08
| Facility | | $2,570.40 | $6,456.54 | $14,791.08 |