- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $4,570.88 / $12,589.25
| Facility | | $954.99 | $4,570.88 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $11,220.18
| Facility | | $2,818.38 | $5,128.61 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $831.76 / $2,630.27
| Professional | | $524.81 | $831.76 | $2,630.27 |
- 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
- $1,698.24 / $4,365.16 / $9,332.54
| Facility | | $1,698.24 | $4,365.16 | $9,332.54 |