- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $421.03 / $2,784.00 / $7,123.00
| Facility | | $421.03 | $2,784.00 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,145.65 / $4,921.76 / $100,491.37
| Facility | | $2,145.65 | $4,921.76 | $100,491.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.18 / $376.50 / $3,031.59
| Professional | | $228.18 | $376.50 | $3,031.59 |
- 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
- $1,300.00 / $5,978.00 / $12,241.00
| Facility | | $1,300.00 | $5,978.00 | $12,241.00 |