- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $3,801.89 / $10,000.00
| Facility | | $741.31 | $3,801.89 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,370.32 / $7,585.78
| Facility | | $2,951.21 | $5,370.32 | $7,585.78 |
- 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
- $380.19 / $616.60 / $1,995.26
| Professional | | $380.19 | $616.60 | $1,995.26 |
- 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
- $1,698.24 / $4,365.16 / $9,332.54
| Facility | | $1,698.24 | $4,365.16 | $9,332.54 |