- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $4,265.80 / $10,000.00
| Facility | | $912.01 | $4,265.80 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,182.57 / $18,197.01
| Facility | | $4,897.79 | $13,182.57 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $6,456.54 / $12,882.50
| Professional | | $524.81 | $6,456.54 | $12,882.50 |
- 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
- $2,570.40 / $7,943.28 / $16,982.44
| Facility | | $2,570.40 | $7,943.28 | $16,982.44 |