- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.74 / $688.00 / $3,636.00
| Facility | | $162.74 | $688.00 | $3,636.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.41 / $895.55 / $1,953.32
| Facility | | $273.41 | $895.55 | $1,953.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.04 / $252.16 / $862.10
| Professional | | $131.04 | $252.16 | $862.10 |
- 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
- $165.00 / $891.00 / $3,685.00
| Facility | | $165.00 | $891.00 | $3,685.00 |