- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,311.31 / $8,511.38
| Facility | | $1,023.29 | $3,311.31 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,311.31 / $14,791.08
| Facility | | $2,511.89 | $3,311.31 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,202.26 / $3,162.28
| Professional | | $741.31 | $1,202.26 | $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
- $1,621.81 / $4,365.16 / $8,128.31
| Facility | | $1,621.81 | $4,365.16 | $8,128.31 |