- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,187.76 / $5,888.44
| Facility | | $1,000.00 | $2,187.76 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,818.38 / $15,848.93
| Facility | | $2,137.96 | $2,818.38 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,230.27 / $2,691.53
| Professional | | $758.58 | $1,230.27 | $2,691.53 |
- 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
- $741.31 / $1,513.56 / $4,168.69
| Facility | | $741.31 | $1,513.56 | $4,168.69 |