- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,187.76 / $5,888.44
| Facility | | $812.83 | $2,187.76 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,786.30 / $8,511.38
| Facility | | $2,089.30 | $4,786.30 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $676.08 / $1,949.84
| Professional | | $426.58 | $676.08 | $1,949.84 |
- 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 |