- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $2,570.40 / $7,762.47
| Facility | | $660.69 | $2,570.40 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,548.13 / $7,762.47
| Facility | | $2,951.21 | $3,548.13 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $549.54 / $1,258.93
| Professional | | $338.84 | $549.54 | $1,258.93 |
- 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
- $1,174.90 / $3,548.13 / $6,309.57
| Facility | | $1,174.90 | $3,548.13 | $6,309.57 |