- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $2,041.74 / $5,623.41
| Facility | | $741.31 | $2,041.74 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,128.61 / $10,471.29
| Facility | | $2,754.23 | $5,128.61 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $302.00 / $1,000.00
| Facility | | $302.00 | $302.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,122.02 / $2,454.71
| Professional | | $616.60 | $1,122.02 | $2,454.71 |
- 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
- $1,584.89 / $4,365.16 / $9,332.54
| Facility | | $1,584.89 | $4,365.16 | $9,332.54 |