- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.46 / $414.18 / $4,200.00
| Facility | | $146.46 | $414.18 | $4,200.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.80 / $838.08 / $1,678.25
| Facility | | $391.80 | $838.08 | $1,678.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.52 / $247.02 / $530.40
| Professional | | $105.52 | $247.02 | $530.40 |
- 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 / $900.00 / $3,686.00
| Facility | | $165.00 | $900.00 | $3,686.00 |