- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $2,187.76 / $5,888.44
| Facility | | $954.99 | $2,187.76 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,548.13 / $15,135.61
| Facility | | $2,951.21 | $3,548.13 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $977.24 / $2,630.27
| Professional | | $537.03 | $977.24 | $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
- $1,174.90 / $3,548.13 / $6,165.95
| Facility | | $1,174.90 | $3,548.13 | $6,165.95 |