- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,843.00 / $2,843.00 / $2,843.00
| Professional | | $2,843.00 | $2,843.00 | $2,843.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,647.88 / $23,741.26 / $41,628.19
| Facility | | $15,647.88 | $23,741.26 | $41,628.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,455.00 / $8,152.00
| Facility | | $1,751.00 | $3,455.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,390.40 / $2,390.40 / $2,390.40
| Professional | | $2,390.40 | $2,390.40 | $2,390.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,500.00 / $8,152.00
| Facility | | $1,751.00 | $3,500.00 | $8,152.00 |