- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,905.46 / $7,762.47
| Facility | | $645.65 | $1,905.46 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,677.35 / $7,585.78
| Facility | | $2,454.71 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $630.96 / $1,862.09
| Professional | | $398.11 | $630.96 | $1,862.09 |
- 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 |