- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,862.09 / $5,888.44
| Facility | | $870.96 | $1,862.09 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,511.38 / $12,022.64
| Facility | | $4,265.80 | $8,511.38 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,230.27 / $3,235.94
| Professional | | $741.31 | $1,230.27 | $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
- $1,288.25 / $4,365.16 / $7,585.78
| Facility | | $1,288.25 | $4,365.16 | $7,585.78 |