- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $9,859.00
| Facility | | $100.00 | $100.00 | $9,859.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,520.23 / $3,520.23 / $3,520.23
| Professional | | $3,520.23 | $3,520.23 | $3,520.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,512.20 / $9,458.00 / $17,400.00
| Facility | | $8,512.20 | $9,458.00 | $17,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.27 / $291.52 / $355.58
| Professional | | $285.27 | $291.52 | $355.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,750.00 / $3,500.00
| Professional | | $2,500.00 | $2,750.00 | $3,500.00 |