- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $3,090.30 / $7,762.47
| Facility | | $645.65 | $3,090.30 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,786.30 / $7,943.28
| Facility | | $3,981.07 | $4,786.30 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $616.60 / $1,584.89
| Professional | | $389.05 | $616.60 | $1,584.89 |
- 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
- $1,513.56 / $3,630.78 / $7,585.78
| Facility | | $1,513.56 | $3,630.78 | $7,585.78 |