- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,884.03 / $7,762.47
| Facility | | $1,023.29 | $2,884.03 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,235.94 / $12,302.69
| Facility | | $2,630.27 | $3,235.94 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,047.13 / $1,905.46
| Professional | | $645.65 | $1,047.13 | $1,905.46 |
- 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 / $2,290.87 / $4,897.79
| Facility | | $1,174.90 | $2,290.87 | $4,897.79 |