- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,715.35 / $9,772.37
| Facility | | $1,258.93 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $18,197.01 / $34,673.69
| Facility | | $6,760.83 | $18,197.01 | $34,673.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,187.76 / $4,677.35
| Professional | | $1,348.96 | $2,187.76 | $4,677.35 |
- 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
- $616.60 / $2,884.03 / $7,413.10
| Facility | | $616.60 | $2,884.03 | $7,413.10 |