- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $1,862.09 / $5,623.41
| Facility | | $269.15 | $1,862.09 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,019.95 / $3,981.07
| Facility | | $1,412.54 | $3,019.95 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $257.04 / $741.31
| Professional | | $169.82 | $257.04 | $741.31 |
- 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
- $1,288.25 / $3,548.13 / $6,165.95
| Facility | | $1,288.25 | $3,548.13 | $6,165.95 |