- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,612.00 / $5,982.00 / $10,871.00
| Facility | | $2,612.00 | $5,982.00 | $10,871.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,705.90 / $5,982.00 / $11,298.00
| Professional | | $1,705.90 | $5,982.00 | $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
- $455.62 / $517.41 / $1,146.61
| Facility | | $455.62 | $517.41 | $1,146.61 |
- 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 |