- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $3,090.30 / $8,511.38
| Facility | | $524.81 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $3,162.28 / $6,165.95
| Facility | | $1,174.90 | $3,162.28 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $467.74 / $1,202.26
| Professional | | $269.15 | $467.74 | $1,202.26 |
- 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 / $4,466.84 / $8,511.38
| Facility | | $1,698.24 | $4,466.84 | $8,511.38 |