- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $663.00 / $2,462.00 / $5,549.00
| Facility | | $663.00 | $2,462.00 | $5,549.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,805.45 / $10,202.07 / $18,157.82
| Facility | | $7,805.45 | $10,202.07 | $18,157.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.36 / $1,284.27 / $3,904.49
| Professional | | $887.36 | $1,284.27 | $3,904.49 |
- 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
- $1,600.00 / $4,530.00 / $8,566.00
| Facility | | $1,600.00 | $4,530.00 | $8,566.00 |