- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $643.84 / $2,462.00 / $5,549.00
| Facility | | $643.84 | $2,462.00 | $5,549.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,878.08 / $5,445.42 / $10,443.56
| Facility | | $3,878.08 | $5,445.42 | $10,443.56 |
- 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
- $526.46 / $767.76 / $2,321.67
| Professional | | $526.46 | $767.76 | $2,321.67 |
- 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 |