- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $2,511.89 / $8,317.64
| Facility | | $309.03 | $2,511.89 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,365.16 / $5,623.41
| Facility | | $2,238.72 | $4,365.16 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $398.11 / $1,000.00
| Professional | | $245.47 | $398.11 | $1,000.00 |
- 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 / $7,585.78
| Facility | | $1,288.25 | $3,548.13 | $7,585.78 |