- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $3,090.30 / $8,511.38
| Facility | | $691.83 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,786.30 / $9,332.54
| Facility | | $1,778.28 | $4,786.30 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $645.65 / $2,290.87
| Professional | | $346.74 | $645.65 | $2,290.87 |
- 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
- $575.44 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |