- 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
- $4,466.84 / $8,128.31 / $13,489.63
| Facility | | $4,466.84 | $8,128.31 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,230.27 / $3,548.13
| Professional | | $741.31 | $1,230.27 | $3,548.13 |
- 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
- $2,570.40 / $6,456.54 / $14,791.08
| Facility | | $2,570.40 | $6,456.54 | $14,791.08 |