- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $880.00 / $10,712.36 / $19,349.05
| Facility | | $880.00 | $10,712.36 | $19,349.05 |
- 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
- $2,900.00 / $3,975.00 / $16,742.18
| Facility | | $2,900.00 | $3,975.00 | $16,742.18 |
- 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
- $1,360.00 / $8,766.00 / $16,556.00
| Facility | | $1,360.00 | $8,766.00 | $16,556.00 |