- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,701.98 / $1,822.00 / $3,344.91
| Facility | | $1,701.98 | $1,822.00 | $3,344.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.98 / $1,701.98 / $1,701.98
| Professional | | $1,701.98 | $1,701.98 | $1,701.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,353.19 / $2,353.19 / $2,353.19
| Professional | | $2,353.19 | $2,353.19 | $2,353.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $3,220.50 / $5,328.00
| Facility | | $55.00 | $3,220.50 | $5,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,489.00 / $14,489.00 / $14,489.00
| Professional | | $14,489.00 | $14,489.00 | $14,489.00 |