- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $1,096.48 / $5,623.41
| Facility | | $173.78 | $1,096.48 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $426.58 / $2,041.74
| Facility | | $316.23 | $426.58 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $208.93 / $467.74
| Professional | | $123.03 | $208.93 | $467.74 |
- 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 / $724.44 / $2,187.76
| Facility | | $158.49 | $724.44 | $2,187.76 |