- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $1,995.26 / $7,762.47
| Facility | | $467.74 | $1,995.26 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,949.84 / $3,801.89
| Facility | | $724.44 | $1,949.84 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $288.40 / $870.96
| Professional | | $173.78 | $288.40 | $870.96 |
- 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
- $151.36 / $851.14 / $2,630.27
| Facility | | $151.36 | $851.14 | $2,630.27 |