- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $2,398.83 / $9,772.37
| Facility | | $100.00 | $2,398.83 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $7,413.10 / $7,413.10
| Professional | | $1,047.13 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $12,022.64 / $22,908.68
| Facility | | $10,964.78 | $12,022.64 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $3,981.07
| Facility | | $2,511.89 | $2,511.89 | $3,981.07 |