- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,760.50 / $5,728.00 / $10,202.00
| Facility | | $2,760.50 | $5,728.00 | $10,202.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,059.00 / $5,728.00 / $11,298.00
| Professional | | $3,059.00 | $5,728.00 | $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
- $477.18 / $477.18 / $1,127.66
| Facility | | $477.18 | $477.18 | $1,127.66 |
- 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 |