- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $4,786.30 / $13,182.57
| Facility | | $446.68 | $4,786.30 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,248.07 / $6,760.83
| Facility | | $2,398.83 | $5,248.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $436.52 / $1,905.46
| Professional | | $281.84 | $436.52 | $1,905.46 |
- 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 |