- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $3,090.30 / $8,709.64
| Facility | | $288.40 | $3,090.30 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,168.69 / $5,495.41
| Facility | | $1,778.28 | $4,168.69 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $263.03 / $1,096.48
| Professional | | $169.82 | $263.03 | $1,096.48 |
- 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 |