- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,995.26 / $7,762.47
| Facility | | $794.33 | $1,995.26 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,897.79 / $16,595.87
| Facility | | $3,981.07 | $4,897.79 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,348.96 / $2,884.03
| Professional | | $812.83 | $1,348.96 | $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
- $1,288.25 / $3,548.13 / $7,585.78
| Facility | | $1,288.25 | $3,548.13 | $7,585.78 |