- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,884.03 / $10,000.00
| Facility | | $812.83 | $2,884.03 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $10,471.29 / $12,589.25
| Facility | | $5,128.61 | $10,471.29 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $10,964.78 / $12,589.25
| Facility | | $5,248.07 | $10,964.78 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,122.02 / $3,090.30
| Professional | | $616.60 | $1,122.02 | $3,090.30 |
- 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
- $2,570.40 / $6,309.57 / $16,982.44
| Facility | | $2,570.40 | $6,309.57 | $16,982.44 |