- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,995.26 / $5,623.41
| Facility | | $630.96 | $1,995.26 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,370.32 / $10,232.93
| Facility | | $1,995.26 | $5,370.32 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $2,089.30 / $3,235.94
| Professional | | $371.54 | $2,089.30 | $3,235.94 |
- 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
- $151.36 / $851.14 / $2,630.27
| Facility | | $151.36 | $851.14 | $2,630.27 |