- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,995.26 / $7,762.47
| Facility | | $489.78 | $1,995.26 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,467.37 / $5,495.41
| Facility | | $2,691.53 | $3,467.37 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $398.11 / $891.25
| Professional | | $234.42 | $398.11 | $891.25 |
- 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
- $1,174.90 / $3,548.13 / $6,309.57
| Facility | | $1,174.90 | $3,548.13 | $6,309.57 |