- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.74 / $1,365.00 / $5,389.00
| Facility | | $165.74 | $1,365.00 | $5,389.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $522.51 / $1,117.68 / $2,238.15
| Facility | | $522.51 | $1,117.68 | $2,238.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.63 / $142.88 / $424.57
| Professional | | $88.63 | $142.88 | $424.57 |
- 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
- $158.00 / $916.00 / $3,606.00
| Facility | | $158.00 | $916.00 | $3,606.00 |