- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $4,786.30 / $11,481.54
| Facility | | $954.99 | $4,786.30 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $10,471.29 / $13,489.63
| Facility | | $6,025.60 | $10,471.29 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $954.99 / $2,238.72
| Professional | | $602.56 | $954.99 | $2,238.72 |
- 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
- $2,570.40 / $6,309.57 / $16,982.44
| Facility | | $2,570.40 | $6,309.57 | $16,982.44 |