- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $2,884.03 / $12,589.25
| Facility | | $537.03 | $2,884.03 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,011.87 / $9,772.37
| Facility | | $1,862.09 | $5,011.87 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $478.63 / $1,659.59
| Professional | | $316.23 | $478.63 | $1,659.59 |
- 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
- $158.49 / $1,995.26 / $24,547.09
| Facility | | $158.49 | $1,995.26 | $24,547.09 |