- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $3,890.45 / $10,000.00
| Facility | | $707.95 | $3,890.45 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $10,471.29 / $14,125.38
| Facility | | $3,715.35 | $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
- $363.08 / $602.56 / $1,905.46
| Professional | | $363.08 | $602.56 | $1,905.46 |
- 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 / $6,918.31 / $16,982.44
| Facility | | $2,570.40 | $6,918.31 | $16,982.44 |