- 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
- $7,079.46 / $13,803.84 / $17,378.01
| Facility | | $7,079.46 | $13,803.84 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,000.00 / $2,691.53
| Professional | | $630.96 | $1,000.00 | $2,691.53 |
- 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 / $5,623.41 / $9,772.37
| Facility | | $1,698.24 | $5,623.41 | $9,772.37 |