- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $2,344.23 / $7,762.47
| Facility | | $870.96 | $2,344.23 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,471.29 / $15,135.61
| Facility | | $7,413.10 | $10,471.29 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,348.96 / $3,019.95
| Professional | | $851.14 | $1,348.96 | $3,019.95 |
- 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
- $1,513.56 / $4,365.16 / $7,585.78
| Facility | | $1,513.56 | $4,365.16 | $7,585.78 |