- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $3,715.35 / $8,511.38
| Facility | | $758.58 | $3,715.35 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $13,182.57
| Facility | | $4,073.80 | $4,897.79 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,000.00 / $2,754.23
| Professional | | $630.96 | $1,000.00 | $2,754.23 |
- 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 / $4,365.16 / $8,912.51
| Facility | | $1,778.28 | $4,365.16 | $8,912.51 |