- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $755.00 / $2,758.00 / $5,580.00
| Facility | | $755.00 | $2,758.00 | $5,580.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,878.08 / $5,445.42 / $10,280.77
| Facility | | $3,878.08 | $5,445.42 | $10,280.77 |
- 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
- $508.00 / $764.46 / $2,281.84
| Professional | | $508.00 | $764.46 | $2,281.84 |
- 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 / $4,530.00 / $8,566.00
| Facility | | $1,600.00 | $4,530.00 | $8,566.00 |