- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $2,187.76 / $6,309.57
| Facility | | $245.47 | $2,187.76 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,388.44 / $4,073.80
| Facility | | $1,445.44 | $3,388.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $229.09 / $794.33
| Professional | | $131.83 | $229.09 | $794.33 |
- 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 |