- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $3,548.13 / $8,912.51
| Facility | | $1,023.29 | $3,548.13 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,548.13 / $15,135.61
| Facility | | $2,951.21 | $3,548.13 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,071.52 / $3,235.94
| Professional | | $575.44 | $1,071.52 | $3,235.94 |
- 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 |