- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $2,884.03 / $9,332.54
| Facility | | $660.69 | $2,884.03 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,370.32 / $7,079.46
| Facility | | $2,951.21 | $5,370.32 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $588.84 / $2,041.74
| Professional | | $346.74 | $588.84 | $2,041.74 |
- 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 / $6,025.60 / $52,480.75
| Facility | | $1,584.89 | $6,025.60 | $52,480.75 |