- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.88 / $1,451.00 / $5,389.00
| Facility | | $192.88 | $1,451.00 | $5,389.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,004.08 / $2,224.94 / $3,964.02
| Facility | | $1,004.08 | $2,224.94 | $3,964.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $463.00 / $463.00 / $480.00
| Facility | | $463.00 | $463.00 | $480.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $162.50 / $504.89
| Professional | | $100.00 | $162.50 | $504.89 |
- 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
- $1,080.00 / $3,951.00 / $6,625.00
| Facility | | $1,080.00 | $3,951.00 | $6,625.00 |