- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $2,341.64 / $10,110.60
| Facility | | $100.00 | $2,341.64 | $10,110.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.50 / $360.50 / $360.50
| Professional | | $360.50 | $360.50 | $360.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,334.70 / $11,483.00 / $21,862.00
| Facility | | $10,334.70 | $11,483.00 | $21,862.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,035.00 / $8,035.00 / $8,035.00
| Facility | | $8,035.00 | $8,035.00 | $8,035.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,750.00 / $3,375.00 / $4,735.00
| Professional | | $2,750.00 | $3,375.00 | $4,735.00 |