- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.27 / $3,627.00 / $56,186.14
| Facility | | $912.27 | $3,627.00 | $56,186.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.27 / $912.27 / $16,537.27
| Professional | | $912.27 | $912.27 | $16,537.27 |
- 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 |