- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,073.80 / $9,772.37
| Facility | | $1,023.29 | $4,073.80 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,548.13 / $13,489.63
| Facility | | $2,951.21 | $3,548.13 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $977.24 / $2,454.71
| Professional | | $512.86 | $977.24 | $2,454.71 |
- 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
- $1,174.90 / $3,548.13 / $6,165.95
| Facility | | $1,174.90 | $3,548.13 | $6,165.95 |