- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $612.37 / $2,758.00 / $5,580.00
| Facility | | $612.37 | $2,758.00 | $5,580.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,475.71 / $4,633.68 / $8,085.55
| Facility | | $3,475.71 | $4,633.68 | $8,085.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.00 / $3,072.73 / $3,430.33
| Facility | | $875.00 | $3,072.73 | $3,430.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.02 / $582.98 / $1,599.10
| Professional | | $380.02 | $582.98 | $1,599.10 |
- 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
- $1,183.00 / $2,435.00 / $4,780.00
| Facility | | $1,183.00 | $2,435.00 | $4,780.00 |