- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $4,365.16 / $14,454.40
| Facility | | $257.04 | $4,365.16 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,548.82 / $2,951.21
| Facility | | $575.44 | $1,548.82 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $229.09 / $1,412.54
| Professional | | $141.25 | $229.09 | $1,412.54 |
- 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 |