- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $3,090.30 / $11,481.54
| Facility | | $630.96 | $3,090.30 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $12,302.69
| Facility | | $4,073.80 | $4,897.79 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $9,772.37 / $10,000.00
| Facility | | $3,090.30 | $9,772.37 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $977.24 / $3,981.07
| Professional | | $602.56 | $977.24 | $3,981.07 |
- 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
- $1,778.28 / $4,365.16 / $8,912.51
| Facility | | $1,778.28 | $4,365.16 | $8,912.51 |