- 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
- $3,090.30 / $3,715.35 / $14,454.40
| Facility | | $3,090.30 | $3,715.35 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $1,023.29 / $4,073.80
| Professional | | $549.54 | $1,023.29 | $4,073.80 |
- 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 |