- 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
- $3,890.45 / $10,471.29 / $19,952.62
| Facility | | $3,890.45 | $10,471.29 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,318.26 / $3,388.44
| Professional | | $741.31 | $1,318.26 | $3,388.44 |
- 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
- $575.44 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |