- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $4,466.84 / $12,589.25
| Facility | | $660.69 | $4,466.84 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,128.61 / $7,762.47
| Facility | | $2,454.71 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $575.44 / $1,905.46
| Professional | | $363.08 | $575.44 | $1,905.46 |
- 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 |