- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,344.23 / $8,511.38
| Facility | | $758.58 | $2,344.23 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,623.41 / $12,589.25
| Facility | | $3,090.30 | $5,623.41 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,000.00 / $3,630.78
| Facility | | $302.00 | $1,000.00 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,348.96 / $3,715.35
| Professional | | $741.31 | $1,348.96 | $3,715.35 |
- 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
- $1,096.48 / $3,548.13 / $7,585.78
| Facility | | $1,096.48 | $3,548.13 | $7,585.78 |