- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $1,862.09 / $5,623.41
| Facility | | $537.03 | $1,862.09 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,238.72 / $6,606.93
| Facility | | $1,318.26 | $2,238.72 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,000.00 / $1,288.25
| Facility | | $302.00 | $1,000.00 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $812.83 / $2,137.96
| Professional | | $457.09 | $812.83 | $2,137.96 |
- 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 / $2,238.72 / $4,677.35
| Facility | | $891.25 | $2,238.72 | $4,677.35 |