- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,166.61 / $3,148.00 / $8,783.00
| Facility | | $1,166.61 | $3,148.00 | $8,783.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,163.33 / $9,692.20 / $19,783.56
| Facility | | $5,163.33 | $9,692.20 | $19,783.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,855.00 / $1,855.00 / $1,923.00
| Facility | | $1,855.00 | $1,855.00 | $1,923.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $989.32 / $1,537.70 / $4,627.42
| Professional | | $989.32 | $1,537.70 | $4,627.42 |
- 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
- $1,602.00 / $7,500.00 / $14,716.00
| Facility | | $1,602.00 | $7,500.00 | $14,716.00 |