- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.00 / $2,951.00 / $10,510.00
| Facility | | $1,017.00 | $2,951.00 | $10,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.30 / $673.30 / $673.30
| Professional | | $673.30 | $673.30 | $673.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,832.00 / $20,514.00 / $37,262.00
| Facility | | $13,832.00 | $20,514.00 | $37,262.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.25 / $362.25 / $362.25
| Professional | | $362.25 | $362.25 | $362.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,840.00 / $10,006.00 / $82,705.00
| Facility | | $7,840.00 | $10,006.00 | $82,705.00 |