- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.87 / $1,265.28 / $3,636.00
| Facility | | $171.87 | $1,265.28 | $3,636.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $567.95 / $1,221.66 / $1,735.36
| Facility | | $567.95 | $1,221.66 | $1,735.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.61 / $864.62 / $1,000.00
| Facility | | $149.61 | $864.62 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.00 / $823.82 / $1,314.83
| Professional | | $120.00 | $823.82 | $1,314.83 |
- 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 |