- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,466.84 / $14,125.38
| Facility | | $1,148.15 | $4,466.84 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,897.79 / $15,135.61
| Facility | | $3,715.35 | $4,897.79 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,288.25 / $3,548.13
| Professional | | $794.33 | $1,288.25 | $3,548.13 |
- 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
- $1,288.25 / $3,548.13 / $7,585.78
| Facility | | $1,288.25 | $3,548.13 | $7,585.78 |