- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.00 / $65.00 / $65.00
| Professional | | $65.00 | $65.00 | $65.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,387.77 / $27,923.57 / $33,415.12
| Facility | | $24,387.77 | $27,923.57 | $33,415.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,007.00 / $6,315.00 / $12,945.00
| Facility | | $3,007.00 | $6,315.00 | $12,945.00 |