- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,961.62 / $8,757.78 / $16,985.45
| Facility | | $7,961.62 | $8,757.78 | $16,985.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,775.00 / $7,961.62 / $7,961.62
| Professional | | $3,775.00 | $7,961.62 | $7,961.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,270.88 / $4,270.88 / $4,270.88
| Professional | | $4,270.88 | $4,270.88 | $4,270.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,014.08 / $26,491.86 / $40,464.55
| Facility | | $15,014.08 | $26,491.86 | $40,464.55 |