- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.98 / $1,819.70 / $5,623.41
| Facility | | $194.98 | $1,819.70 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,090.30 / $4,073.80
| Facility | | $1,148.15 | $3,090.30 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $338.84 / $1,047.13
| Professional | | $109.65 | $338.84 | $1,047.13 |
- 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
- $1,174.90 / $3,548.13 / $6,309.57
| Facility | | $1,174.90 | $3,548.13 | $6,309.57 |