- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.98 / $1,278.00 / $10,688.16
| Facility | | $540.98 | $1,278.00 | $10,688.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,368.39 / $5,066.08 / $10,144.82
| Facility | | $2,368.39 | $5,066.08 | $10,144.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.80 / $473.82 / $1,568.71
| Professional | | $329.80 | $473.82 | $1,568.71 |
- 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
- $204.00 / $2,224.00 / $23,753.00
| Facility | | $204.00 | $2,224.00 | $23,753.00 |