- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,676.91 / $1,768.00 / $2,987.43
| Facility | | $1,676.91 | $1,768.00 | $2,987.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,676.91 / $1,676.91 / $1,676.91
| Professional | | $1,676.91 | $1,676.91 | $1,676.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.00 / $2,243.00 / $2,243.00
| Professional | | $2,243.00 | $2,243.00 | $2,243.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $3,079.75 / $5,091.57
| Facility | | $55.00 | $3,079.75 | $5,091.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,233.00 / $14,233.00 / $14,233.00
| Professional | | $14,233.00 | $14,233.00 | $14,233.00 |