- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $5,495.41 / $12,302.69
| Facility | | $870.96 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $13,803.84 / $18,197.01
| Facility | | $6,165.95 | $13,803.84 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $4,365.16 / $6,309.57
| Professional | | $512.86 | $4,365.16 | $6,309.57 |
- 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 / $7,943.28 / $16,982.44
| Facility | | $2,570.40 | $7,943.28 | $16,982.44 |