- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $3,467.37 / $9,772.37
| Facility | | $812.83 | $3,467.37 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $6,025.60 / $11,481.54
| Facility | | $2,238.72 | $6,025.60 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $741.31 / $2,290.87
| Professional | | $467.74 | $741.31 | $2,290.87 |
- 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
- $1,584.89 / $5,495.41 / $8,511.38
| Facility | | $1,584.89 | $5,495.41 | $8,511.38 |