- 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
- $2,818.38 / $7,585.78 / $14,791.08
| Facility | | $2,818.38 | $7,585.78 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,047.13 / $3,467.37
| Professional | | $645.65 | $1,047.13 | $3,467.37 |
- 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 |