- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $907.48 / $2,676.11 / $5,580.00
| Facility | | $907.48 | $2,676.11 | $5,580.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,538.45 / $11,757.71 / $21,220.15
| Facility | | $8,538.45 | $11,757.71 | $21,220.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.00 / $6,831.39 / $7,626.43
| Facility | | $875.00 | $6,831.39 | $7,626.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.75 / $1,514.48 / $3,076.87
| Professional | | $1,036.75 | $1,514.48 | $3,076.87 |
- 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
- $2,575.00 / $6,920.00 / $14,716.00
| Facility | | $2,575.00 | $6,920.00 | $14,716.00 |