- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.84 / $163.51 / $232.48
| Facility | | $124.84 | $163.51 | $232.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $249.55 / $689.68 / $2,744.72
| Facility | | $249.55 | $689.68 | $2,744.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.37 / $154.54 / $435.06
| Professional | | $114.37 | $154.54 | $435.06 |
- 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
- $578.00 / $2,873.00 / $7,384.00
| Facility | | $578.00 | $2,873.00 | $7,384.00 |