- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $784.00 / $1,831.00 / $2,010.00
| Facility | | $784.00 | $1,831.00 | $2,010.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27,926.45 / $27,926.45 / $33,397.06
| Facility | | $27,926.45 | $27,926.45 | $33,397.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,829.14 / $14,829.14 / $14,829.14
| Professional | | $14,829.14 | $14,829.14 | $14,829.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,566.42 / $13,566.42 / $13,566.42
| Facility | | $13,566.42 | $13,566.42 | $13,566.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,360.00 / $8,766.00 / $15,000.00
| Facility | | $1,360.00 | $8,766.00 | $15,000.00 |