- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,995.26 / $7,762.47
| Facility | | $741.31 | $1,995.26 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,951.21 / $10,232.93
| Facility | | $2,398.83 | $2,951.21 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $831.76 / $3,388.44
| Professional | | $416.87 | $831.76 | $3,388.44 |
- 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 / $6,165.95
| Facility | | $1,288.25 | $3,548.13 | $6,165.95 |