- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,038.00 / $5,743.00 / $9,403.00
| Facility | | $3,038.00 | $5,743.00 | $9,403.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,616.00 / $2,843.00 / $8,194.00
| Professional | | $2,616.00 | $2,843.00 | $8,194.00 |
- 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
- $20,314.50 / $25,330.44 / $36,365.48
| Facility | | $20,314.50 | $25,330.44 | $36,365.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $9,753.00 / $15,824.00
| Facility | | $3,028.00 | $9,753.00 | $15,824.00 |