- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.24 / $222.00 / $348.17
| Facility | | $120.24 | $222.00 | $348.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,123.83 / $2,141.84 / $2,990.43
| Facility | | $1,123.83 | $2,141.84 | $2,990.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.16 / $198.65 / $990.61
| Professional | | $128.16 | $198.65 | $990.61 |
- 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
- $1,183.00 / $2,664.00 / $5,026.00
| Facility | | $1,183.00 | $2,664.00 | $5,026.00 |