- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.88 / $3,090.30 / $8,511.38
| Facility | | $154.88 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $954.99 / $1,819.70
| Facility | | $354.81 | $954.99 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $141.25 / $457.09
| Professional | | $91.20 | $141.25 | $457.09 |
- 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
- $707.95 / $2,137.96 / $4,570.88
| Facility | | $707.95 | $2,137.96 | $4,570.88 |