- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $2,187.76 / $7,413.10
| Facility | | $489.78 | $2,187.76 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,570.88 / $6,456.54
| Facility | | $2,290.87 | $4,570.88 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $407.38 / $1,412.54
| Professional | | $263.03 | $407.38 | $1,412.54 |
- 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 / $4,365.16 / $8,912.51
| Facility | | $1,698.24 | $4,365.16 | $8,912.51 |