- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.13 / $7,943.28 / $16,595.87
| Facility | | $89.13 | $7,943.28 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $213.80 / $213.80
| Facility | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.86 / $97.72 / $128.82
| Facility | | $75.86 | $97.72 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $6,760.83 / $10,000.00
| Facility | | $1,479.11 | $6,760.83 | $10,000.00 |