- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $586.16 / $1,664.40 / $5,549.00
| Facility | | $586.16 | $1,664.40 | $5,549.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,594.32 / $5,549.36 / $11,112.59
| Facility | | $2,594.32 | $5,549.36 | $11,112.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.00 / $875.00 / $908.00
| Facility | | $875.00 | $875.00 | $908.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.83 / $804.60 / $2,402.06
| Professional | | $496.83 | $804.60 | $2,402.06 |
- 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
- $578.00 / $2,873.00 / $7,384.00
| Facility | | $578.00 | $2,873.00 | $7,384.00 |