- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $1,380.38 / $5,623.41
| Facility | | $112.20 | $1,380.38 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $676.08 / $1,698.24
| Facility | | $562.34 | $676.08 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $107.15 / $380.19
| Professional | | $67.61 | $107.15 | $380.19 |
- 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 / $758.58 / $2,187.76
| Facility | | $158.49 | $758.58 | $2,187.76 |