- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,995.26 / $7,762.47
| Facility | | $602.56 | $1,995.26 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $14,454.40 / $19,054.61
| Facility | | $3,235.94 | $14,454.40 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,498.45 / $19,498.45 / $19,498.45
| Facility | | $19,498.45 | $19,498.45 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $537.03 / $2,691.53
| Professional | | $338.84 | $537.03 | $2,691.53 |
- 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 / $9,772.37 / $25,703.96
| Facility | | $3,311.31 | $9,772.37 | $25,703.96 |