- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,090.30 / $8,511.38
| Facility | | $1,023.29 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $12,302.69 / $23,442.29
| Facility | | $4,570.88 | $12,302.69 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,513.56 / $5,248.07
| Professional | | $912.01 | $1,513.56 | $5,248.07 |
- 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
- $575.44 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |