- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $880.80 / $2,118.00 / $5,405.00
| Facility | | $880.80 | $2,118.00 | $5,405.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,295.45 / $9,442.92 / $20,596.22
| Facility | | $4,295.45 | $9,442.92 | $20,596.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.63 / $1,443.47 / $3,810.32
| Professional | | $963.63 | $1,443.47 | $3,810.32 |
- 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 |