- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $3,235.94 / $8,128.31
| Facility | | $354.81 | $3,235.94 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,786.30 / $6,456.54
| Facility | | $2,187.76 | $4,786.30 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $316.23 / $1,071.52
| Professional | | $204.17 | $316.23 | $1,071.52 |
- 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 |