- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $2,511.89 / $8,511.38
| Facility | | $537.03 | $2,511.89 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,128.61 / $7,244.36
| Facility | | $2,454.71 | $5,128.61 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $457.09 / $1,258.93
| Professional | | $295.12 | $457.09 | $1,258.93 |
- 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 |