- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $3,235.94 / $8,511.38
| Facility | | $812.83 | $3,235.94 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,677.35 / $13,182.57
| Facility | | $3,235.94 | $4,677.35 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $831.76 / $2,570.40
| Professional | | $478.63 | $831.76 | $2,570.40 |
- 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
- $660.69 / $1,949.84 / $4,466.84
| Facility | | $660.69 | $1,949.84 | $4,466.84 |