- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,760.70 / $7,655.00 / $13,151.00
| Facility | | $1,760.70 | $7,655.00 | $13,151.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.52 / $62.52 / $3,600.00
| Professional | | $62.52 | $62.52 | $3,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,533.00 / $11,533.00 / $11,533.00
| Facility | | $11,533.00 | $11,533.00 | $11,533.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.44 / $1,087.00 / $5,897.00
| Facility | | $260.44 | $1,087.00 | $5,897.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $191.00 / $550.00 / $1,769.00
| Facility | | $191.00 | $550.00 | $1,769.00 |