- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $1,621.81 / $5,623.41
| Facility | | $295.12 | $1,621.81 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,096.48 / $3,162.28
| Facility | | $891.25 | $1,096.48 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $416.87 / $831.76
| Professional | | $208.93 | $416.87 | $831.76 |
- 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 / $3,715.35
| Facility | | $588.84 | $1,479.11 | $3,715.35 |