- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.03 / $1,905.46 / $5,888.44
| Facility | | $123.03 | $1,905.46 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $4,466.84 / $6,025.60
| Facility | | $891.25 | $4,466.84 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $109.65 / $346.74
| Professional | | $74.13 | $109.65 | $346.74 |
- 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
- $891.25 / $2,818.38 / $5,128.61
| Facility | | $891.25 | $2,818.38 | $5,128.61 |