- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,089.30 / $7,762.47
| Facility | | $977.24 | $2,089.30 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $13,803.84 / $19,498.45
| Facility | | $7,079.46 | $13,803.84 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,230.27 / $3,162.28
| Professional | | $758.58 | $1,230.27 | $3,162.28 |
- 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 / $4,365.16 / $8,511.38
| Facility | | $1,288.25 | $4,365.16 | $8,511.38 |