- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,884.03 / $9,332.54
| Facility | | $1,023.29 | $2,884.03 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,715.35 / $15,135.61
| Facility | | $3,090.30 | $3,715.35 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,096.48 / $3,090.30
| Professional | | $575.44 | $1,096.48 | $3,090.30 |
- 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 |