- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $2,570.40 / $7,762.47
| Facility | | $630.96 | $2,570.40 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,079.46 / $9,120.11
| Facility | | $3,235.94 | $7,079.46 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $602.56 / $1,548.82
| Professional | | $380.19 | $602.56 | $1,548.82 |
- 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 |