- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $450.00 / $942.00
| Professional | | $250.00 | $450.00 | $942.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.85 / $1,969.88 / $6,390.91
| Facility | | $1,650.85 | $1,969.88 | $6,390.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $680.00 / $680.00
| Facility | | $680.00 | $680.00 | $680.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |