- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,995.26 / $7,762.47
| Facility | | $707.95 | $1,995.26 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,011.87 / $9,772.37
| Facility | | $1,862.09 | $5,011.87 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $645.65 / $2,818.38
| Professional | | $398.11 | $645.65 | $2,818.38 |
- 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
- $151.36 / $851.14 / $2,630.27
| Facility | | $151.36 | $851.14 | $2,630.27 |