- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,884.03 / $8,511.38
| Facility | | $933.25 | $2,884.03 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,548.13 / $10,964.78
| Facility | | $2,951.21 | $3,548.13 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $870.96 / $2,398.83
| Professional | | $478.63 | $870.96 | $2,398.83 |
- 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
- $1,174.90 / $3,548.13 / $6,165.95
| Facility | | $1,174.90 | $3,548.13 | $6,165.95 |