- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $3,090.30 / $8,511.38
| Facility | | $812.83 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,128.61 / $12,302.69
| Facility | | $3,019.95 | $5,128.61 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $831.76 / $2,951.21
| Professional | | $524.81 | $831.76 | $2,951.21 |
- 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
- $1,288.25 / $3,548.13 / $7,585.78
| Facility | | $1,288.25 | $3,548.13 | $7,585.78 |