- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,862.09 / $5,888.44
| Facility | | $616.60 | $1,862.09 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,786.30 / $6,760.83
| Facility | | $2,089.30 | $4,786.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $512.86 / $1,995.26
| Professional | | $331.13 | $512.86 | $1,995.26 |
- 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
- $1,288.25 / $3,548.13 / $7,585.78
| Facility | | $1,288.25 | $3,548.13 | $7,585.78 |