- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $966.02 / $3,270.00 / $14,823.00
| Facility | | $966.02 | $3,270.00 | $14,823.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,509.75 / $4,493.79 / $14,712.58
| Facility | | $1,509.75 | $4,493.79 | $14,712.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.84 / $891.87 / $2,823.39
| Professional | | $622.84 | $891.87 | $2,823.39 |
- 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
- $1,602.00 / $8,802.00 / $24,668.00
| Facility | | $1,602.00 | $8,802.00 | $24,668.00 |