- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,884.03 / $9,332.54
| Facility | | $724.44 | $2,884.03 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $13,182.57 / $18,197.01
| Facility | | $4,570.88 | $13,182.57 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $660.69 / $1,862.09
| Professional | | $371.54 | $660.69 | $1,862.09 |
- 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
- $2,041.74 / $6,606.93 / $12,882.50
| Facility | | $2,041.74 | $6,606.93 | $12,882.50 |