- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.57 / $1,875.00 / $10,227.06
| Facility | | $511.57 | $1,875.00 | $10,227.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $967.61 / $2,299.51 / $8,447.56
| Facility | | $967.61 | $2,299.51 | $8,447.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,636.00 / $16,636.00 / $16,636.00
| Facility | | $16,636.00 | $16,636.00 | $16,636.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.05 / $450.29 / $1,592.22
| Professional | | $312.05 | $450.29 | $1,592.22 |
- 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
- $204.00 / $2,575.00 / $19,000.00
| Facility | | $204.00 | $2,575.00 | $19,000.00 |