- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $2,344.23 / $7,762.47
| Facility | | $537.03 | $2,344.23 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $11,748.98
| Facility | | $4,073.80 | $4,897.79 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,000.00 / $3,715.35
| Professional | | $575.44 | $1,000.00 | $3,715.35 |
- 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
- $1,513.56 / $3,630.78 / $7,585.78
| Facility | | $1,513.56 | $3,630.78 | $7,585.78 |