- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $3,090.30 / $8,511.38
| Facility | | $954.99 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $11,220.18 / $21,379.62
| Facility | | $4,073.80 | $11,220.18 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,380.38 / $5,495.41
| Professional | | $812.83 | $1,380.38 | $5,495.41 |
- 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 |