- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,753.77 / $5,948.91 / $14,287.65
| Facility | | $2,753.77 | $5,948.91 | $14,287.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,859.17 / $3,859.17 / $8,775.00
| Professional | | $3,859.17 | $3,859.17 | $8,775.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.50 / $1,326.50 / $1,326.50
| Professional | | $1,326.50 | $1,326.50 | $1,326.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $5,409.35 / $5,409.35
| Facility | | $100.00 | $5,409.35 | $5,409.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,983.66 / $3,983.66 / $3,983.66
| Professional | | $3,983.66 | $3,983.66 | $3,983.66 |