- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,888.44 / $16,595.87
| Facility | | $3,801.89 | $5,888.44 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $891.25
| Facility | | $177.83 | $177.83 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $229.09 / $229.09
| Professional | | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $123.03 / $204.17
| Facility | | $100.00 | $123.03 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $1,202.26 / $3,548.13
| Facility | | $354.81 | $1,202.26 | $3,548.13 |