- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $3,090.30 / $8,511.38
| Facility | | $331.13 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,905.46 / $3,715.35
| Facility | | $707.95 | $1,905.46 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $288.40 / $933.25
| Professional | | $177.83 | $288.40 | $933.25 |
- 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
- $575.44 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |