- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,884.03 / $9,549.93
| Facility | | $831.76 | $2,884.03 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,244.36 / $10,232.93
| Facility | | $3,235.94 | $7,244.36 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $812.83 / $2,137.96
| Professional | | $512.86 | $812.83 | $2,137.96 |
- 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 / $4,073.80 / $7,585.78
| Facility | | $1,288.25 | $4,073.80 | $7,585.78 |