- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $1,862.09 / $9,772.37
| Facility | | $363.08 | $1,862.09 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,019.95 / $5,754.40
| Facility | | $1,122.02 | $3,019.95 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $436.52 / $1,380.38
| Professional | | $269.15 | $436.52 | $1,380.38 |
- 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
- $3,630.78 / $12,302.69 / $41,686.94
| Facility | | $3,630.78 | $12,302.69 | $41,686.94 |