- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,570.40 / $7,762.47
| Facility | | $977.24 | $2,570.40 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,165.95 / $18,620.87
| Facility | | $5,011.87 | $6,165.95 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,288.25 / $3,890.45
| Professional | | $707.95 | $1,288.25 | $3,890.45 |
- 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
- $1,584.89 / $4,365.16 / $9,332.54
| Facility | | $1,584.89 | $4,365.16 | $9,332.54 |