- 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
- $2,951.21 / $3,981.07 / $25,118.86
| Facility | | $2,951.21 | $3,981.07 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,819.70 / $5,011.87
| Professional | | $954.99 | $1,819.70 | $5,011.87 |
- 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 |