- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,246.06 / $9,062.00 / $24,649.00
| Facility | | $4,246.06 | $9,062.00 | $24,649.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,062.00 / $9,062.00 / $15,307.00
| Professional | | $9,062.00 | $9,062.00 | $15,307.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,020.13 / $9,722.31 / $14,962.41
| Facility | | $5,020.13 | $9,722.31 | $14,962.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $16,959.00 / $23,485.00
| Facility | | $2,912.00 | $16,959.00 | $23,485.00 |