- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $2,570.40 / $8,511.38
| Facility | | $467.74 | $2,570.40 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,311.31 / $6,309.57
| Facility | | $1,230.27 | $3,311.31 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $407.38 / $1,288.25
| Professional | | $263.03 | $407.38 | $1,288.25 |
- 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
- $151.36 / $831.76 / $2,630.27
| Facility | | $151.36 | $831.76 | $2,630.27 |