- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $813.00 / $2,758.00 / $5,580.00
| Facility | | $813.00 | $2,758.00 | $5,580.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,889.58 / $6,779.12 / $14,786.12
| Facility | | $3,889.58 | $6,779.12 | $14,786.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.00 / $3,072.73 / $3,430.33
| Facility | | $875.00 | $3,072.73 | $3,430.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.75 / $1,022.95 / $2,240.19
| Professional | | $623.75 | $1,022.95 | $2,240.19 |
- 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
- $1,499.00 / $3,751.00 / $6,514.00
| Facility | | $1,499.00 | $3,751.00 | $6,514.00 |