- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,187.76 / $5,888.44
| Facility | | $812.83 | $2,187.76 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,709.64 / $11,481.54
| Facility | | $4,265.80 | $8,709.64 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $851.14 / $2,454.71
| Professional | | $524.81 | $851.14 | $2,454.71 |
- 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 / $15,488.17
| Facility | | $2,570.40 | $6,456.54 | $15,488.17 |