- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $974.00 / $3,035.00 / $7,123.00
| Facility | | $974.00 | $3,035.00 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,790.56 / $7,967.09 / $22,712.15
| Facility | | $2,790.56 | $7,967.09 | $22,712.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.52 / $1,343.33 / $7,098.00
| Professional | | $959.52 | $1,343.33 | $7,098.00 |
- 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
- $1,600.00 / $4,469.00 / $8,566.00
| Facility | | $1,600.00 | $4,469.00 | $8,566.00 |