- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $637.03 / $1,289.00 / $5,091.00
| Facility | | $637.03 | $1,289.00 | $5,091.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,889.58 / $6,388.93 / $13,935.06
| Facility | | $3,889.58 | $6,388.93 | $13,935.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $463.00 / $3,072.73 / $3,430.33
| Facility | | $463.00 | $3,072.73 | $3,430.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $674.00 / $1,005.17 / $2,148.44
| Professional | | $674.00 | $1,005.17 | $2,148.44 |
- 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 / $2,705.80 / $4,780.00
| Facility | | $1,183.00 | $2,705.80 | $4,780.00 |