- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $2,187.76 / $5,888.44
| Facility | | $467.74 | $2,187.76 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,019.95 / $5,754.40
| Facility | | $1,412.54 | $3,019.95 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $398.11 / $933.25
| Professional | | $257.04 | $398.11 | $933.25 |
- 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 / $6,165.95
| Facility | | $1,288.25 | $3,548.13 | $6,165.95 |