- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.10 / $1,272.00 / $4,646.83
| Facility | | $271.10 | $1,272.00 | $4,646.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $924.63 / $2,274.07 / $3,355.49
| Facility | | $924.63 | $2,274.07 | $3,355.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.00 / $1,000.00 / $2,769.00
| Facility | | $300.00 | $1,000.00 | $2,769.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.77 / $511.10 / $1,083.23
| Professional | | $192.77 | $511.10 | $1,083.23 |
- 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
- $815.00 / $2,588.00 / $4,780.00
| Facility | | $815.00 | $2,588.00 | $4,780.00 |