- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,378.00 / $1,530.37 / $2,788.18
| Facility | | $1,378.00 | $1,530.37 | $2,788.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.37 / $1,530.37 / $1,530.37
| Professional | | $1,530.37 | $1,530.37 | $1,530.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $1,927.40 / $2,770.10
| Professional | | $7.00 | $1,927.40 | $2,770.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $2,930.37 / $4,634.55
| Facility | | $55.00 | $2,930.37 | $4,634.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,711.23 / $8,711.23 / $8,711.23
| Professional | | $8,711.23 | $8,711.23 | $8,711.23 |