- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $807.52 / $1,848.00 / $5,389.00
| Facility | | $807.52 | $1,848.00 | $5,389.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,138.27 / $7,607.33 / $16,592.56
| Facility | | $3,138.27 | $7,607.33 | $16,592.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $620.00 / $620.00 / $643.00
| Facility | | $620.00 | $620.00 | $643.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.42 / $1,090.72 / $2,928.02
| Professional | | $649.42 | $1,090.72 | $2,928.02 |
- 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
- $1,080.00 / $3,951.00 / $6,625.00
| Facility | | $1,080.00 | $3,951.00 | $6,625.00 |