- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $2,089.30 / $7,079.46
| Facility | | $707.95 | $2,089.30 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,019.95 / $9,120.11
| Facility | | $2,511.89 | $3,019.95 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $724.44 / $1,778.28
| Professional | | $467.74 | $724.44 | $1,778.28 |
- 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
- $1,513.56 / $3,548.13 / $6,165.95
| Facility | | $1,513.56 | $3,548.13 | $6,165.95 |