- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $3,548.13 / $9,772.37
| Facility | | $630.96 | $3,548.13 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $7,585.78 / $9,549.93
| Facility | | $3,890.45 | $7,585.78 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $524.81 / $2,041.74
| Professional | | $338.84 | $524.81 | $2,041.74 |
- 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 |