- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,570.40 / $7,762.47
| Facility | | $933.25 | $2,570.40 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $7,762.47 / $19,054.61
| Facility | | $4,677.35 | $7,762.47 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,318.26 / $3,548.13
| Professional | | $812.83 | $1,318.26 | $3,548.13 |
- 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
- $1,698.24 / $4,365.16 / $9,772.37
| Facility | | $1,698.24 | $4,365.16 | $9,772.37 |