- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.05 / $5,031.20 / $15,093.60
| Facility | | $0.05 | $5,031.20 | $15,093.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $7,546.80
| Professional | | $2,000.00 | $2,000.00 | $7,546.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $846.27 / $15,093.60 / $27,314.38
| Facility | | $846.27 | $15,093.60 | $27,314.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $846.27 / $1,140.08
| Professional | | $100.00 | $846.27 | $1,140.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,031.20 / $6,540.56 / $7,043.68
| Facility | | $5,031.20 | $6,540.56 | $7,043.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,031.20 / $6,037.44 / $7,546.80
| Professional | | $5,031.20 | $6,037.44 | $7,546.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,270.28 / $5,031.20 / $11,213.81
| Facility | | $3,270.28 | $5,031.20 | $11,213.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.08 / $4,583.45 / $7,342.62
| Professional | | $1,117.08 | $4,583.45 | $7,342.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.10 / $3,018.72 / $5,529.29
| Professional | | $2,113.10 | $3,018.72 | $5,529.29 |