- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $4,265.80 / $14,125.38
| Facility | | $1,071.52 | $4,265.80 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,511.38 / $13,489.63
| Facility | | $4,265.80 | $8,511.38 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,148.15 / $3,235.94
| Professional | | $707.95 | $1,148.15 | $3,235.94 |
- 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
- $2,089.30 / $5,370.32 / $12,302.69
| Facility | | $2,089.30 | $5,370.32 | $12,302.69 |