- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.27 / $1,233.27 / $4,634.00
| Facility | | $588.27 | $1,233.27 | $4,634.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,225.03 / $3,202.34 / $6,984.72
| Facility | | $1,225.03 | $3,202.34 | $6,984.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $463.00 / $929.98 / $1,038.21
| Facility | | $463.00 | $929.98 | $1,038.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.87 / $878.28 / $2,826.80
| Professional | | $428.87 | $878.28 | $2,826.80 |
- 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
- $807.00 / $1,900.00 / $4,256.00
| Facility | | $807.00 | $1,900.00 | $4,256.00 |