- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.83 / $1,486.00 / $4,634.00
| Facility | | $524.83 | $1,486.00 | $4,634.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,889.34 / $4,464.57 / $6,721.48
| Facility | | $2,889.34 | $4,464.57 | $6,721.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $620.00 / $3,072.73 / $3,430.33
| Facility | | $620.00 | $3,072.73 | $3,430.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.15 / $668.25 / $1,625.48
| Professional | | $395.15 | $668.25 | $1,625.48 |
- 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
- $1,499.00 / $3,751.00 / $6,514.00
| Facility | | $1,499.00 | $3,751.00 | $6,514.00 |