- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $3,715.35 / $10,000.00
| Facility | | $316.23 | $3,715.35 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $10,471.29 / $14,125.38
| Facility | | $1,621.81 | $10,471.29 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $275.42 / $1,023.29
| Professional | | $173.78 | $275.42 | $1,023.29 |
- 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 / $6,918.31 / $16,982.44
| Facility | | $2,570.40 | $6,918.31 | $16,982.44 |