- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $3,090.30 / $10,000.00
| Facility | | $616.60 | $3,090.30 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $10,471.29 / $14,125.38
| Facility | | $3,235.94 | $10,471.29 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $12,589.25 / $28,840.32
| Facility | | $9,120.11 | $12,589.25 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $537.03 / $1,621.81
| Professional | | $346.74 | $537.03 | $1,621.81 |
- 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
- $3,311.31 / $9,332.54 / $28,840.32
| Facility | | $3,311.31 | $9,332.54 | $28,840.32 |