- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,511.89 / $9,772.37
| Facility | | $645.65 | $2,511.89 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,951.21 / $5,888.44
| Facility | | $1,584.89 | $2,951.21 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $549.54 / $1,548.82
| Professional | | $346.74 | $549.54 | $1,548.82 |
- 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 / $4,897.79
| Facility | | $891.25 | $2,290.87 | $4,897.79 |