- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,633.00 / $5,412.00 / $14,187.00
| Facility | | $3,633.00 | $5,412.00 | $14,187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,520.23 / $3,520.23 / $3,633.00
| Professional | | $3,520.23 | $3,520.23 | $3,633.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,823.00 / $12,004.00 / $15,528.00
| Facility | | $9,823.00 | $12,004.00 | $15,528.00 |
- 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
- $640.00 / $640.00 / $640.00
| Facility | | $640.00 | $640.00 | $640.00 |