- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,995.26 / $5,623.41
| Facility | | $346.74 | $1,995.26 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,023.29 / $2,238.72
| Facility | | $549.54 | $1,023.29 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $158.49 / $602.56
| Professional | | $102.33 | $158.49 | $602.56 |
- 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
- $588.84 / $1,479.11 / $3,801.89
| Facility | | $588.84 | $1,479.11 | $3,801.89 |