- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $3,548.13 / $8,912.51
| Facility | | $549.54 | $3,548.13 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,398.83 / $4,677.35
| Facility | | $891.25 | $2,398.83 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $234.42 / $1,862.09
| Professional | | $125.89 | $234.42 | $1,862.09 |
- 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
- $151.36 / $831.76 / $2,630.27
| Facility | | $151.36 | $831.76 | $2,630.27 |