- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,187.76 / $5,888.44
| Facility | | $933.25 | $2,187.76 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $12,589.25
| Facility | | $4,073.80 | $4,897.79 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $977.24 / $2,570.40
| Professional | | $602.56 | $977.24 | $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
- $1,778.28 / $4,365.16 / $8,912.51
| Facility | | $1,778.28 | $4,365.16 | $8,912.51 |