- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $440.55 / $1,230.03 / $4,634.00
| Facility | | $440.55 | $1,230.03 | $4,634.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $943.83 / $2,114.05 / $4,490.37
| Facility | | $943.83 | $2,114.05 | $4,490.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.00 / $480.00 / $1,231.60
| Facility | | $300.00 | $480.00 | $1,231.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.08 / $821.70 / $1,658.70
| Professional | | $308.08 | $821.70 | $1,658.70 |
- 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 |