- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,380.38 / $5,623.41
| Facility | | $501.19 | $1,380.38 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,467.37 / $6,025.60
| Facility | | $2,951.21 | $3,467.37 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $630.96 / $1,819.70
| Professional | | $331.13 | $630.96 | $1,819.70 |
- 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 |