- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,235.94 / $9,772.37
| Facility | | $602.56 | $3,235.94 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,548.13 / $6,918.31
| Facility | | $1,318.26 | $3,548.13 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $524.81 / $1,778.28
| Professional | | $331.13 | $524.81 | $1,778.28 |
- 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 |