- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,344.23 / $7,762.47
| Facility | | $831.76 | $2,344.23 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $16,982.44
| Facility | | $4,168.69 | $5,128.61 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,288.25 / $3,311.31
| Professional | | $794.33 | $1,288.25 | $3,311.31 |
- 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 |