- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.84 / $1,363.00 / $5,389.00
| Facility | | $327.84 | $1,363.00 | $5,389.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $883.16 / $1,889.12 / $3,782.96
| Facility | | $883.16 | $1,889.12 | $3,782.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.82 / $1,015.38 / $1,925.40
| Professional | | $235.82 | $1,015.38 | $1,925.40 |
- 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 |