- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $721.45 / $2,462.00 / $5,500.00
| Facility | | $721.45 | $2,462.00 | $5,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,878.08 / $5,895.67 / $11,816.08
| Facility | | $3,878.08 | $5,895.67 | $11,816.08 |
- 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
- $584.52 / $876.78 / $2,586.09
| Professional | | $584.52 | $876.78 | $2,586.09 |
- 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 |