- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,570.40 / $8,511.38
| Facility | | $812.83 | $2,570.40 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,471.29 / $15,135.61
| Facility | | $7,413.10 | $10,471.29 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,288.25 / $4,265.80
| Professional | | $741.31 | $1,288.25 | $4,265.80 |
- 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
- $2,570.40 / $6,309.57 / $16,982.44
| Facility | | $2,570.40 | $6,309.57 | $16,982.44 |