- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $374.13 / $1,652.67 / $4,961.00
| Facility | | $374.13 | $1,652.67 | $4,961.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $966.64 / $2,229.44 / $3,732.86
| Facility | | $966.64 | $2,229.44 | $3,732.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $328.18 / $785.00 / $1,378.17
| Facility | | $328.18 | $785.00 | $1,378.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.26 / $1,159.84 / $1,730.50
| Professional | | $260.26 | $1,159.84 | $1,730.50 |
- 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 |