- 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 / $6,763.74 / $14,752.59
| Facility | | $3,889.58 | $6,763.74 | $14,752.59 |
- 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
- $709.40 / $1,039.90 / $3,616.54
| Professional | | $709.40 | $1,039.90 | $3,616.54 |
- 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
- $1,787.00 / $4,803.00 / $8,821.00
| Facility | | $1,787.00 | $4,803.00 | $8,821.00 |