- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $1,621.81 / $5,623.41
| Facility | | $389.05 | $1,621.81 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,265.80 / $5,754.40
| Facility | | $2,089.30 | $4,265.80 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,000.00 / $2,691.53
| Facility | | $302.00 | $1,000.00 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $616.60 / $1,548.82
| Professional | | $331.13 | $616.60 | $1,548.82 |
- 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
- $891.25 / $2,691.53 / $5,128.61
| Facility | | $891.25 | $2,691.53 | $5,128.61 |