- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $3,090.30 / $8,511.38
| Facility | | $416.87 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,691.53 / $5,248.07
| Facility | | $1,000.00 | $2,691.53 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $363.08 / $1,479.11
| Professional | | $234.42 | $363.08 | $1,479.11 |
- 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 |