- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.00 / $2,747.00 / $14,536.00
| Facility | | $860.00 | $2,747.00 | $14,536.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.86 / $19,207.86 / $19,207.86
| Professional | | $933.86 | $19,207.86 | $19,207.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,584.00 / $25,962.00 / $33,917.00
| Facility | | $16,584.00 | $25,962.00 | $33,917.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.01 / $8.01 / $8.01
| Professional | | $8.01 | $8.01 | $8.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,600.00 / $13,184.00 / $33,203.00
| Facility | | $1,600.00 | $13,184.00 | $33,203.00 |