- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,344.23 / $7,762.47
| Facility | | $891.25 | $2,344.23 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,128.61 / $14,791.08
| Facility | | $4,073.80 | $5,128.61 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,096.48 / $3,162.28
| Professional | | $691.83 | $1,096.48 | $3,162.28 |
- 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
- $1,096.48 / $2,691.53 / $5,128.61
| Facility | | $1,096.48 | $2,691.53 | $5,128.61 |