- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,548.13 / $8,912.51
| Facility | | $933.25 | $3,548.13 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $10,471.29 / $12,882.50
| Facility | | $5,495.41 | $10,471.29 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $870.96 / $2,344.23
| Professional | | $549.54 | $870.96 | $2,344.23 |
- 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
- $1,778.28 / $5,495.41 / $9,772.37
| Facility | | $1,778.28 | $5,495.41 | $9,772.37 |