- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $5,495.41 / $12,589.25
| Facility | | $1,258.93 | $5,495.41 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,709.64 / $15,848.93
| Facility | | $4,265.80 | $8,709.64 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,318.26 / $3,388.44
| Professional | | $776.25 | $1,318.26 | $3,388.44 |
- 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
- $2,570.40 / $6,456.54 / $15,488.17
| Facility | | $2,570.40 | $6,456.54 | $15,488.17 |