- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,801.89 / $12,882.50
| Facility | | $1,023.29 | $3,801.89 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,715.35 / $12,022.64
| Facility | | $3,090.30 | $3,715.35 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $977.24 / $2,041.74
| Professional | | $524.81 | $977.24 | $2,041.74 |
- 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 / $6,309.57
| Facility | | $1,174.90 | $3,548.13 | $6,309.57 |