- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,757.91 / $5,560.00 / $8,968.08
| Facility | | $4,757.91 | $5,560.00 | $8,968.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,450.48 / $4,356.00 / $9,101.51
| Professional | | $3,450.48 | $4,356.00 | $9,101.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,938.00 / $9,782.46 / $9,782.46
| Professional | | $2,938.00 | $9,782.46 | $9,782.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.40 / $58.40 / $58.40
| Professional | | $58.40 | $58.40 | $58.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,604.80 / $11,604.80 / $11,604.80
| Facility | | $11,604.80 | $11,604.80 | $11,604.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,575.48 / $9,782.46 / $9,782.46
| Professional | | $5,575.48 | $9,782.46 | $9,782.46 |