- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.30 / $303.30 / $4,828.00
| Facility | | $303.30 | $303.30 | $4,828.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.40 / $1,222.40 / $1,222.40
| Professional | | $1,222.40 | $1,222.40 | $1,222.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,771.16 / $13,307.77 / $23,333.99
| Facility | | $8,771.16 | $13,307.77 | $23,333.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,940.00 / $10,380.00 / $19,301.97
| Facility | | $3,940.00 | $10,380.00 | $19,301.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,331.00 / $11,165.00 / $19,301.97
| Facility | | $5,331.00 | $11,165.00 | $19,301.97 |