- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $3,235.94 / $9,772.37
| Facility | | $758.58 | $3,235.94 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,370.32 / $10,471.29
| Facility | | $1,995.26 | $5,370.32 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $794.33 / $2,570.40
| Professional | | $457.09 | $794.33 | $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
- $575.44 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |