- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,466.84 / $12,882.50
| Facility | | $1,148.15 | $4,466.84 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,715.35 / $16,595.87
| Facility | | $2,951.21 | $3,715.35 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,174.90 / $2,884.03
| Professional | | $630.96 | $1,174.90 | $2,884.03 |
- 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
- $1,174.90 / $3,548.13 / $6,165.95
| Facility | | $1,174.90 | $3,548.13 | $6,165.95 |