- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.43 / $1,835.00 / $5,091.00
| Facility | | $455.43 | $1,835.00 | $5,091.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,179.36 / $2,621.59 / $4,624.60
| Facility | | $1,179.36 | $2,621.59 | $4,624.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.00 / $1,300.00 / $2,769.00
| Facility | | $400.00 | $1,300.00 | $2,769.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.02 / $392.72 / $1,271.61
| Professional | | $273.02 | $392.72 | $1,271.61 |
- 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
- $815.00 / $2,588.00 / $4,780.00
| Facility | | $815.00 | $2,588.00 | $4,780.00 |