- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $370.50 / $370.50 / $740.99
| Facility | | $370.50 | $370.50 | $740.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,271.26 / $4,302.59 / $8,322.61
| Facility | | $3,271.26 | $4,302.59 | $8,322.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.08 / $1,242.00 / $4,406.00
| Facility | | $289.08 | $1,242.00 | $4,406.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.16 / $2,117.16 / $2,117.16
| Professional | | $2,117.16 | $2,117.16 | $2,117.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,031.00 / $1,775.00 / $4,406.00
| Facility | | $1,031.00 | $1,775.00 | $4,406.00 |