- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,862.09 / $7,762.47
| Facility | | $588.84 | $1,862.09 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,677.35 / $6,760.83
| Facility | | $2,089.30 | $4,677.35 | $6,760.83 |
- 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
- $446.68 / $724.44 / $1,659.59
| Professional | | $446.68 | $724.44 | $1,659.59 |
- 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 |