- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,288.25 / $5,623.41
| Facility | | $588.84 | $1,288.25 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $9,120.11
| Facility | | $2,089.30 | $2,511.89 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $724.44 / $1,698.24
| Professional | | $467.74 | $724.44 | $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
- $158.49 / $1,023.29 / $3,235.94
| Facility | | $158.49 | $1,023.29 | $3,235.94 |