- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,073.80 / $9,772.37
| Facility | | $1,122.02 | $4,073.80 | $9,772.37 |
- 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 / $3,890.45
| Professional | | $630.96 | $1,174.90 | $3,890.45 |
- 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
- $831.76 / $2,290.87 / $5,011.87
| Facility | | $831.76 | $2,290.87 | $5,011.87 |