- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,090.30 / $8,511.38
| Facility | | $933.25 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $15,135.61
| Facility | | $4,168.69 | $5,128.61 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,202.26 / $3,311.31
| Professional | | $741.31 | $1,202.26 | $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
- $1,949.84 / $7,943.28 / $21,877.62
| Facility | | $1,949.84 | $7,943.28 | $21,877.62 |