- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $1,995.26 / $7,762.47
| Facility | | $173.78 | $1,995.26 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $1,230.27 / $2,398.83
| Facility | | $457.09 | $1,230.27 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $162.18 / $457.09
| Professional | | $100.00 | $162.18 | $457.09 |
- 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 |