- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,630.18 / $19,827.11 / $40,757.56
| Facility | | $1,630.18 | $19,827.11 | $40,757.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.18 / $1,630.18 / $11,668.86
| Professional | | $1,630.18 | $1,630.18 | $11,668.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,785.00 / $22,599.50 / $29,073.50
| Facility | | $11,785.00 | $22,599.50 | $29,073.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.01 / $20.01 / $20.01
| Professional | | $20.01 | $20.01 | $20.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |