- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $3,090.30 / $8,511.38
| Facility | | $630.96 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $4,677.35 / $8,912.51
| Facility | | $1,737.80 | $4,677.35 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $676.08 / $1,819.70
| Professional | | $380.19 | $676.08 | $1,819.70 |
- 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
- $616.60 / $2,951.21 / $7,413.10
| Facility | | $616.60 | $2,951.21 | $7,413.10 |