- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,715.35 / $9,772.37
| Facility | | $1,122.02 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $12,589.25 / $23,988.33
| Facility | | $4,677.35 | $12,589.25 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,584.89 / $3,548.13
| Professional | | $977.24 | $1,584.89 | $3,548.13 |
- 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
- $1,288.25 / $3,388.44 / $6,165.95
| Facility | | $1,288.25 | $3,388.44 | $6,165.95 |