- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.61 / $735.00 / $3,636.00
| Facility | | $60.61 | $735.00 | $3,636.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.52 / $467.44 / $936.04
| Facility | | $218.52 | $467.44 | $936.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.12 / $200.32 / $341.67
| Professional | | $51.12 | $200.32 | $341.67 |
- 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 |