- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,995.26 / $7,762.47
| Facility | | $616.60 | $1,995.26 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,290.87 / $6,606.93
| Facility | | $1,621.81 | $2,290.87 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $512.86 / $1,258.93
| Professional | | $316.23 | $512.86 | $1,258.93 |
- 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
- $891.25 / $2,290.87 / $4,786.30
| Facility | | $891.25 | $2,290.87 | $4,786.30 |