- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,288.25 / $5,623.41
| Facility | | $512.86 | $1,288.25 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,570.40 / $7,585.78
| Facility | | $2,137.96 | $2,570.40 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $812.83 / $2,290.87
| Professional | | $426.58 | $812.83 | $2,290.87 |
- 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
- $741.31 / $1,513.56 / $4,168.69
| Facility | | $741.31 | $1,513.56 | $4,168.69 |