- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $2,344.23 / $7,762.47
| Facility | | $537.03 | $2,344.23 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $6,760.83 / $8,709.64
| Facility | | $3,235.94 | $6,760.83 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $549.54 / $1,621.81
| Professional | | $346.74 | $549.54 | $1,621.81 |
- 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
- $2,089.30 / $5,370.32 / $12,302.69
| Facility | | $2,089.30 | $5,370.32 | $12,302.69 |