- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $1,778.28 / $6,918.31
| Facility | | $147.91 | $1,778.28 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $851.14 / $1,659.59
| Facility | | $316.23 | $851.14 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $323.59 / $758.58
| Professional | | $95.50 | $323.59 | $758.58 |
- 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 / $831.76 / $2,630.27
| Facility | | $151.36 | $831.76 | $2,630.27 |