- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $1,621.81 / $5,623.41
| Facility | | $114.82 | $1,621.81 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,041.74 / $2,691.53
| Facility | | $891.25 | $2,041.74 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $169.82 / $389.05
| Professional | | $85.11 | $169.82 | $389.05 |
- 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
- $660.69 / $1,479.11 / $4,168.69
| Facility | | $660.69 | $1,479.11 | $4,168.69 |