- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $830.59 / $2,758.00 / $5,580.00
| Facility | | $830.59 | $2,758.00 | $5,580.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,295.45 / $8,904.64 / $19,422.16
| Facility | | $4,295.45 | $8,904.64 | $19,422.16 |
- 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
- $927.51 / $1,358.03 / $3,717.96
| Professional | | $927.51 | $1,358.03 | $3,717.96 |
- 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 / $4,530.00 / $8,566.00
| Facility | | $1,600.00 | $4,530.00 | $8,566.00 |