- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,715.35 / $9,772.37
| Facility | | $891.25 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $7,762.47 / $11,220.18
| Facility | | $3,890.45 | $7,762.47 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $776.25 / $2,238.72
| Professional | | $478.63 | $776.25 | $2,238.72 |
- 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
- $1,288.25 / $4,265.80 / $7,585.78
| Facility | | $1,288.25 | $4,265.80 | $7,585.78 |