- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,884.03 / $9,332.54
| Facility | | $933.25 | $2,884.03 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $15,488.17
| Facility | | $4,168.69 | $5,128.61 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,202.26 / $2,691.53
| Professional | | $758.58 | $1,202.26 | $2,691.53 |
- 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
- $1,412.54 / $3,548.13 / $7,244.36
| Facility | | $1,412.54 | $3,548.13 | $7,244.36 |