- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $8,431.00 / $10,303.00
| Facility | | $2,747.00 | $8,431.00 | $10,303.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,420.34 / $2,420.34 / $7,836.38
| Professional | | $2,420.34 | $2,420.34 | $7,836.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.89 / $15,027.18 / $17,076.34
| Professional | | $900.89 | $15,027.18 | $17,076.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,340.00 / $3,340.00 / $3,340.00
| Facility | | $3,340.00 | $3,340.00 | $3,340.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.41 / $1,414.50 / $1,534.13
| Professional | | $733.41 | $1,414.50 | $1,534.13 |