- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,862.09 / $5,888.44
| Facility | | $398.11 | $1,862.09 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,019.95 / $5,754.40
| Facility | | $1,122.02 | $3,019.95 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $407.38 / $1,288.25
| Professional | | $269.15 | $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 / $851.14 / $2,630.27
| Facility | | $151.36 | $851.14 | $2,630.27 |