- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,884.03 / $7,762.47
| Facility | | $831.76 | $2,884.03 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $13,182.57
| Facility | | $2,089.30 | $2,754.23 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,000.00 / $2,570.40
| Professional | | $616.60 | $1,000.00 | $2,570.40 |
- 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
- $1,096.48 / $2,290.87 / $4,786.30
| Facility | | $1,096.48 | $2,290.87 | $4,786.30 |