- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $4,466.84 / $9,332.54
| Facility | | $575.44 | $4,466.84 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,128.61 / $7,585.78
| Facility | | $2,454.71 | $5,128.61 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $562.34 / $1,778.28
| Professional | | $346.74 | $562.34 | $1,778.28 |
- 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 / $9,332.54
| Facility | | $1,698.24 | $4,365.16 | $9,332.54 |