- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,715.35 / $9,772.37
| Facility | | $1,023.29 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $10,471.29 / $20,417.38
| Facility | | $3,890.45 | $10,471.29 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,318.26 / $3,162.28
| Professional | | $794.33 | $1,318.26 | $3,162.28 |
- 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
- $1,584.89 / $4,265.80 / $8,128.31
| Facility | | $1,584.89 | $4,265.80 | $8,128.31 |