- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $413.73 / $2,660.00 / $5,580.00
| Facility | | $413.73 | $2,660.00 | $5,580.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,681.81 / $5,820.76 / $9,185.06
| Facility | | $2,681.81 | $5,820.76 | $9,185.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $463.00 / $463.00 / $480.00
| Facility | | $463.00 | $463.00 | $480.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.68 / $345.40 / $1,577.00
| Professional | | $227.68 | $345.40 | $1,577.00 |
- 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
- $1,602.00 / $7,500.00 / $14,716.00
| Facility | | $1,602.00 | $7,500.00 | $14,716.00 |