- 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
- $1,348.96 / $3,630.78 / $7,079.46
| Facility | | $1,348.96 | $3,630.78 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $371.54 / $1,174.90
| Professional | | $234.42 | $371.54 | $1,174.90 |
- 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 |