- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.77 / $2,824.00 / $5,580.00
| Facility | | $950.77 | $2,824.00 | $5,580.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,846.66 / $9,262.18 / $20,202.00
| Facility | | $4,846.66 | $9,262.18 | $20,202.00 |
- 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
- $1,011.77 / $1,640.20 / $5,010.85
| Professional | | $1,011.77 | $1,640.20 | $5,010.85 |
- 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
- $1,690.00 / $5,000.00 / $8,995.00
| Facility | | $1,690.00 | $5,000.00 | $8,995.00 |