- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.27 / $2,784.00 / $7,125.00
| Facility | | $315.27 | $2,784.00 | $7,125.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.48 / $2,255.64 / $3,683.38
| Facility | | $1,200.48 | $2,255.64 | $3,683.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.36 / $284.51 / $2,666.12
| Professional | | $185.36 | $284.51 | $2,666.12 |
- 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
- $749.00 / $2,622.00 / $5,026.00
| Facility | | $749.00 | $2,622.00 | $5,026.00 |