- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $2,187.76 / $7,762.47
| Facility | | $741.31 | $2,187.76 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $7,762.47 / $15,135.61
| Facility | | $3,890.45 | $7,762.47 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,071.52 / $2,884.03
| Professional | | $645.65 | $1,071.52 | $2,884.03 |
- 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 / $6,456.54 / $14,454.40
| Facility | | $2,570.40 | $6,456.54 | $14,454.40 |