- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,862.09 / $7,762.47
| Facility | | $416.87 | $1,862.09 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,168.69 / $5,370.32
| Facility | | $2,290.87 | $4,168.69 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $562.34 / $1,202.26
| Professional | | $275.42 | $562.34 | $1,202.26 |
- 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
- $1,584.89 / $3,630.78 / $7,079.46
| Facility | | $1,584.89 | $3,630.78 | $7,079.46 |