- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,089.30 / $8,511.38
| Facility | | $724.44 | $2,089.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,128.61 / $8,709.64
| Facility | | $2,454.71 | $5,128.61 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $630.96 / $1,445.44
| Professional | | $398.11 | $630.96 | $1,445.44 |
- 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 / $3,548.13 / $7,585.78
| Facility | | $1,288.25 | $3,548.13 | $7,585.78 |