- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.32 / $1,363.00 / $5,389.00
| Facility | | $133.32 | $1,363.00 | $5,389.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $466.27 / $1,206.98 / $1,663.16
| Facility | | $466.27 | $1,206.98 | $1,663.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.73 / $93.73 / $93.73
| Facility | | $93.73 | $93.73 | $93.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.06 / $177.58 / $836.50
| Professional | | $92.06 | $177.58 | $836.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |