- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $3,235.94 / $9,549.93
| Facility | | $707.95 | $3,235.94 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,265.80 / $8,511.38
| Facility | | $3,548.13 | $4,265.80 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $870.96 / $1,819.70
| Professional | | $489.78 | $870.96 | $1,819.70 |
- 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
- $1,584.89 / $3,630.78 / $7,079.46
| Facility | | $1,584.89 | $3,630.78 | $7,079.46 |