- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $2,187.76 / $6,606.93
| Facility | | $851.14 | $2,187.76 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,128.61 / $12,022.64
| Facility | | $2,951.21 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $891.25 / $2,290.87
| Professional | | $549.54 | $891.25 | $2,290.87 |
- 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 |