- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $923.00 / $2,747.00 / $5,500.00
| Facility | | $923.00 | $2,747.00 | $5,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,295.45 / $7,880.45 / $17,188.25
| Facility | | $4,295.45 | $7,880.45 | $17,188.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.38 / $1,274.35 / $3,270.64
| Professional | | $847.38 | $1,274.35 | $3,270.64 |
- 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
- $2,100.00 / $5,820.00 / $12,241.00
| Facility | | $2,100.00 | $5,820.00 | $12,241.00 |