- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,286.00 / $5,647.00 / $10,692.00
| Facility | | $2,286.00 | $5,647.00 | $10,692.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,057.17 / $8,057.17 / $8,057.17
| Professional | | $8,057.17 | $8,057.17 | $8,057.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.70 / $662.70 / $662.70
| Professional | | $662.70 | $662.70 | $662.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,369.84 / $9,249.58 / $18,785.34
| Facility | | $8,369.84 | $9,249.58 | $18,785.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,885.00 / $7,188.00 / $10,536.00
| Facility | | $3,885.00 | $7,188.00 | $10,536.00 |