- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $858.80 / $4,200.00 / $11,872.80
| Facility | | $858.80 | $4,200.00 | $11,872.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,882.14 / $8,806.20 / $17,473.09
| Facility | | $2,882.14 | $8,806.20 | $17,473.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.00 / $785.00 / $13,923.25
| Facility | | $400.00 | $785.00 | $13,923.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $609.41 / $7,558.36 / $11,243.74
| Professional | | $609.41 | $7,558.36 | $11,243.74 |
- 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
- $1,400.00 / $6,920.00 / $16,667.00
| Facility | | $1,400.00 | $6,920.00 | $16,667.00 |