- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $1,621.81 / $7,762.47
| Facility | | $537.03 | $1,621.81 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $10,715.19 / $20,892.96
| Facility | | $3,981.07 | $10,715.19 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,348.96 / $7,079.46
| Professional | | $851.14 | $1,348.96 | $7,079.46 |
- 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
- $151.36 / $851.14 / $2,630.27
| Facility | | $151.36 | $851.14 | $2,630.27 |