- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,995.26 / $7,762.47
| Facility | | $758.58 | $1,995.26 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $16,595.87
| Facility | | $2,089.30 | $2,754.23 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,258.93 / $3,388.44
| Professional | | $794.33 | $1,258.93 | $3,388.44 |
- 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
- $831.76 / $2,511.89 / $4,786.30
| Facility | | $831.76 | $2,511.89 | $4,786.30 |