- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,911.68 / $36,093.81 / $36,093.81
| Facility | | $19,911.68 | $36,093.81 | $36,093.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.00 / $4,856.00 / $4,916.51
| Professional | | $2,398.00 | $4,856.00 | $4,916.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $930.21 / $3,430.14 / $6,085.89
| Facility | | $930.21 | $3,430.14 | $6,085.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.66 / $930.21 / $1,267.41
| Professional | | $697.66 | $930.21 | $1,267.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.00 / $2,398.00 / $5,341.60
| Facility | | $2,398.00 | $2,398.00 | $5,341.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,453.46 / $2,453.46 / $2,453.46
| Professional | | $2,453.46 | $2,453.46 | $2,453.46 |