- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $3,090.30 / $8,511.38
| Facility | | $288.40 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,737.80 / $3,311.31
| Facility | | $645.65 | $1,737.80 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $263.03 / $776.25
| Professional | | $162.18 | $263.03 | $776.25 |
- 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 |