- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.68 / $3,250.00 / $8,108.37
| Facility | | $391.68 | $3,250.00 | $8,108.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.34 / $3,876.24 / $5,510.44
| Facility | | $1,518.34 | $3,876.24 | $5,510.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.74 / $875.00 / $2,713.32
| Facility | | $263.74 | $875.00 | $2,713.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.22 / $377.78 / $1,026.72
| Professional | | $260.22 | $377.78 | $1,026.72 |
- 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
- $1,098.00 / $3,951.00 / $6,482.00
| Facility | | $1,098.00 | $3,951.00 | $6,482.00 |