- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,041.74 / $7,762.47
| Facility | | $398.11 | $2,041.74 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $707.95 / $3,630.78
| Facility | | $524.81 | $707.95 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $323.59 / $977.24
| Professional | | $199.53 | $323.59 | $977.24 |
- 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 / $758.58 / $2,187.76
| Facility | | $158.49 | $758.58 | $2,187.76 |