- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $460.53 / $1,278.00 / $5,549.00
| Facility | | $460.53 | $1,278.00 | $5,549.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,560.55 / $3,338.08 / $6,684.50
| Facility | | $1,560.55 | $3,338.08 | $6,684.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.33 / $463.24 / $1,293.04
| Professional | | $299.33 | $463.24 | $1,293.04 |
- 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
- $165.00 / $900.00 / $3,686.00
| Facility | | $165.00 | $900.00 | $3,686.00 |