- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,286.00 / $5,695.00 / $10,692.00
| Facility | | $2,286.00 | $5,695.00 | $10,692.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,286.00 / $6,153.00 / $11,298.00
| Professional | | $2,286.00 | $6,153.00 | $11,298.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55,249.45 / $55,249.45 / $55,249.45
| Professional | | $55,249.45 | $55,249.45 | $55,249.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $583.20 / $663.08 / $1,264.67
| Facility | | $583.20 | $663.08 | $1,264.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,529.00 / $3,352.00 / $10,536.00
| Facility | | $1,529.00 | $3,352.00 | $10,536.00 |