- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $987.59 / $2,784.00 / $6,661.00
| Facility | | $987.59 | $2,784.00 | $6,661.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,027.12 / $12,892.24 / $25,816.71
| Facility | | $6,027.12 | $12,892.24 | $25,816.71 |
- 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
- $1,112.52 / $1,638.04 / $5,242.81
| Professional | | $1,112.52 | $1,638.04 | $5,242.81 |
- 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
- $2,100.00 / $5,619.00 / $12,241.00
| Facility | | $2,100.00 | $5,619.00 | $12,241.00 |