- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $739.65 / $2,747.00 / $7,780.00
| Facility | | $739.65 | $2,747.00 | $7,780.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,420.83 / $4,863.03 / $9,612.56
| Facility | | $3,420.83 | $4,863.03 | $9,612.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,383.00 / $2,338.66 / $2,610.83
| Facility | | $1,383.00 | $2,338.66 | $2,610.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.29 / $860.68 / $2,309.63
| Professional | | $533.29 | $860.68 | $2,309.63 |
- 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
- $1,600.00 / $3,493.00 / $6,482.00
| Facility | | $1,600.00 | $3,493.00 | $6,482.00 |