- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $475.53 / $1,842.00 / $5,430.00
| Facility | | $475.53 | $1,842.00 | $5,430.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,197.71 / $4,683.43 / $6,725.86
| Facility | | $2,197.71 | $4,683.43 | $6,725.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $620.00 / $7,701.00 / $11,011.00
| Facility | | $620.00 | $7,701.00 | $11,011.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.72 / $403.95 / $1,687.84
| Professional | | $277.72 | $403.95 | $1,687.84 |
- 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
- $1,152.00 / $5,000.00 / $8,995.00
| Facility | | $1,152.00 | $5,000.00 | $8,995.00 |