- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,705.16 / $3,161.20 / $5,098.89
| Facility | | $2,705.16 | $3,161.20 | $5,098.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.81 / $2,476.65 / $5,174.76
| Professional | | $1,961.81 | $2,476.65 | $5,174.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,210.00 / $7,854.00 / $7,854.00
| Professional | | $2,210.00 | $7,854.00 | $7,854.00 |
- 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
- $4,623.18 / $4,623.18 / $4,623.18
| Facility | | $4,623.18 | $4,623.18 | $4,623.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,782.89 / $7,854.00 / $7,854.00
| Professional | | $3,782.89 | $7,854.00 | $7,854.00 |