- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $3,090.30 / $8,511.38
| Facility | | $537.03 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,165.95 / $12,022.64
| Facility | | $2,290.87 | $6,165.95 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $851.14 / $2,137.96
| Professional | | $501.19 | $851.14 | $2,137.96 |
- 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 |