- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.33 / $1,229.00 / $5,091.00
| Facility | | $236.33 | $1,229.00 | $5,091.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $644.28 / $1,378.16 / $2,759.76
| Facility | | $644.28 | $1,378.16 | $2,759.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.72 / $765.10 / $1,544.40
| Professional | | $174.72 | $765.10 | $1,544.40 |
- 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 |