- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,570.40 / $9,332.54
| Facility | | $1,122.02 | $2,570.40 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $6,456.54 / $21,877.62
| Facility | | $5,370.32 | $6,456.54 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,698.24 / $5,128.61
| Professional | | $912.01 | $1,698.24 | $5,128.61 |
- 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
- $1,513.56 / $5,370.32 / $12,302.69
| Facility | | $1,513.56 | $5,370.32 | $12,302.69 |