- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,884.03 / $7,762.47
| Facility | | $1,122.02 | $2,884.03 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,548.13 / $21,877.62
| Facility | | $2,630.27 | $3,548.13 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,862.09 / $5,495.41
| Professional | | $1,148.15 | $1,862.09 | $5,495.41 |
- 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 |