- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $3,090.30 / $9,772.37
| Facility | | $630.96 | $3,090.30 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $6,760.83 / $12,882.50
| Facility | | $2,511.89 | $6,760.83 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $630.96 / $2,137.96
| Professional | | $380.19 | $630.96 | $2,137.96 |
- 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
- $575.44 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |