- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,344.23 / $7,762.47
| Facility | | $831.76 | $2,344.23 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $10,471.29 / $14,454.40
| Facility | | $6,606.93 | $10,471.29 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,148.15 / $3,235.94
| Professional | | $645.65 | $1,148.15 | $3,235.94 |
- 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
- $1,412.54 / $4,265.80 / $7,585.78
| Facility | | $1,412.54 | $4,265.80 | $7,585.78 |