- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $3,090.30 / $10,000.00
| Facility | | $588.84 | $3,090.30 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,570.88 / $6,165.95
| Facility | | $2,290.87 | $4,570.88 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $524.81 / $1,348.96
| Professional | | $323.59 | $524.81 | $1,348.96 |
- 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
- $1,698.24 / $4,365.16 / $8,912.51
| Facility | | $1,698.24 | $4,365.16 | $8,912.51 |