- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,884.03 / $8,511.38
| Facility | | $933.25 | $2,884.03 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $12,022.64
| Facility | | $4,073.80 | $4,897.79 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $933.25 / $3,162.28
| Professional | | $588.84 | $933.25 | $3,162.28 |
- 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 |