- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $2,754.23 / $8,511.38
| Facility | | $602.56 | $2,754.23 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $7,762.47 / $10,471.29
| Facility | | $3,548.13 | $7,762.47 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $537.03 / $1,659.59
| Professional | | $338.84 | $537.03 | $1,659.59 |
- 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
- $2,041.74 / $5,370.32 / $12,302.69
| Facility | | $2,041.74 | $5,370.32 | $12,302.69 |