- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $3,090.30 / $8,511.38
| Facility | | $977.24 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $10,715.19 / $20,417.38
| Facility | | $3,981.07 | $10,715.19 | $20,417.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $588.84
| Facility | | $398.11 | $398.11 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,698.24 / $4,677.35
| Professional | | $933.25 | $1,698.24 | $4,677.35 |
- 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 / $2,818.38 / $7,413.10
| Facility | | $575.44 | $2,818.38 | $7,413.10 |