- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $3,548.13 / $8,912.51
| Facility | | $977.24 | $3,548.13 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $10,471.29 / $13,489.63
| Facility | | $6,165.95 | $10,471.29 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $977.24 / $3,890.45
| Professional | | $602.56 | $977.24 | $3,890.45 |
- 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 / $7,244.36 / $16,982.44
| Facility | | $1,778.28 | $7,244.36 | $16,982.44 |