- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,621.81 / $5,623.41
| Facility | | $436.52 | $1,621.81 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,168.69 / $5,888.44
| Facility | | $2,818.38 | $4,168.69 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $645.65 / $1,380.38
| Professional | | $338.84 | $645.65 | $1,380.38 |
- 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
- $1,513.56 / $3,630.78 / $7,079.46
| Facility | | $1,513.56 | $3,630.78 | $7,079.46 |