- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,995.26 / $7,762.47
| Facility | | $630.96 | $1,995.26 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,128.61 / $8,128.31
| Facility | | $2,454.71 | $5,128.61 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $602.56 / $1,698.24
| Professional | | $371.54 | $602.56 | $1,698.24 |
- 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
- $2,089.30 / $5,370.32 / $12,302.69
| Facility | | $2,089.30 | $5,370.32 | $12,302.69 |