- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $1,737.80 / $5,623.41
| Facility | | $186.21 | $1,737.80 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $2,137.96 / $2,818.38
| Facility | | $954.99 | $2,137.96 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $239.88 / $549.54
| Professional | | $117.49 | $239.88 | $549.54 |
- 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
- $891.25 / $2,290.87 / $4,786.30
| Facility | | $891.25 | $2,290.87 | $4,786.30 |