- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $768.45 / $2,824.00 / $5,500.00
| Facility | | $768.45 | $2,824.00 | $5,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,878.08 / $5,266.44 / $9,504.79
| Facility | | $3,878.08 | $5,266.44 | $9,504.79 |
- 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
- $562.11 / $2,442.66 / $4,928.95
| Professional | | $562.11 | $2,442.66 | $4,928.95 |
- 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
- $1,600.00 / $4,342.00 / $8,168.00
| Facility | | $1,600.00 | $4,342.00 | $8,168.00 |