- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,572.00 / $5,841.00 / $10,871.00
| Facility | | $2,572.00 | $5,841.00 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,297.00 / $6,396.00 / $12,384.00
| Professional | | $3,297.00 | $6,396.00 | $12,384.00 |
- 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
- $455.62 / $455.62 / $1,002.03
| Facility | | $455.62 | $455.62 | $1,002.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.00 / $3,339.00 / $9,152.00
| Facility | | $1,200.00 | $3,339.00 | $9,152.00 |