- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $374.13 / $1,471.00 / $4,611.50
| Facility | | $374.13 | $1,471.00 | $4,611.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,239.00 / $2,317.26 / $3,732.86
| Facility | | $1,239.00 | $2,317.26 | $3,732.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $328.70 / $587.00 / $908.00
| Facility | | $328.70 | $587.00 | $908.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.67 / $1,167.32 / $1,744.57
| Professional | | $260.67 | $1,167.32 | $1,744.57 |
- 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 |