- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $2,884.03 / $7,762.47
| Facility | | $776.25 | $2,884.03 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,467.37 / $9,120.11
| Facility | | $2,884.03 | $3,467.37 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $660.69 / $1,778.28
| Professional | | $363.08 | $660.69 | $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
- $831.76 / $2,290.87 / $5,011.87
| Facility | | $831.76 | $2,290.87 | $5,011.87 |