- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.23 / $223.87 / $1,122.02
| Facility | | $120.23 | $223.87 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,238.72 / $2,818.38
| Facility | | $1,202.26 | $2,238.72 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $204.17 / $1,148.15
| Professional | | $131.83 | $204.17 | $1,148.15 |
- 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
- $1,174.90 / $2,290.87 / $4,786.30
| Facility | | $1,174.90 | $2,290.87 | $4,786.30 |