- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,673.00 / $10,673.00 / $10,673.00
| Facility | | $10,673.00 | $10,673.00 | $10,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.16 / $1,395.16 / $1,395.16
| Professional | | $1,395.16 | $1,395.16 | $1,395.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,833.93 / $2,947.28 / $6,339.86
| Facility | | $2,833.93 | $2,947.28 | $6,339.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,023.91 / $2,023.91 / $2,224.30
| Professional | | $2,023.91 | $2,023.91 | $2,224.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.54 / $3,544.93 / $3,544.93
| Professional | | $2,005.54 | $3,544.93 | $3,544.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $469.55 / $670.79 / $1,777.59
| Professional | | $469.55 | $670.79 | $1,777.59 |