- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $1,621.81 / $5,623.41
| Facility | | $223.87 | $1,621.81 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,023.29 / $1,698.24
| Facility | | $831.76 | $1,023.29 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $346.74 / $1,047.13
| Professional | | $117.49 | $346.74 | $1,047.13 |
- 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 / $1,479.11 / $3,715.35
| Facility | | $575.44 | $1,479.11 | $3,715.35 |