- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $967.68 / $2,774.51 / $5,580.00
| Facility | | $967.68 | $2,774.51 | $5,580.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,166.89 / $7,054.06 / $16,409.84
| Facility | | $4,166.89 | $7,054.06 | $16,409.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.00 / $875.00 / $908.00
| Facility | | $875.00 | $875.00 | $908.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.78 / $1,294.52 / $4,193.55
| Professional | | $834.78 | $1,294.52 | $4,193.55 |
- 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
- $1,152.00 / $5,000.00 / $8,995.00
| Facility | | $1,152.00 | $5,000.00 | $8,995.00 |