- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $810.47 / $2,747.00 / $7,123.00
| Facility | | $810.47 | $2,747.00 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,801.55 / $5,992.64 / $12,000.26
| Facility | | $2,801.55 | $5,992.64 | $12,000.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.00 / $875.00 / $908.00
| Facility | | $875.00 | $875.00 | $908.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.58 / $759.71 / $2,287.04
| Professional | | $491.58 | $759.71 | $2,287.04 |
- 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
- $1,152.00 / $4,803.00 / $8,995.00
| Facility | | $1,152.00 | $4,803.00 | $8,995.00 |