- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.00 / $1,842.00 / $5,272.97
| Facility | | $630.00 | $1,842.00 | $5,272.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,488.03 / $5,322.00 / $10,657.30
| Facility | | $2,488.03 | $5,322.00 | $10,657.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.58 / $2,087.48 / $3,246.43
| Professional | | $432.58 | $2,087.48 | $3,246.43 |
- 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 |