- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,856.00 / $6,162.00 / $18,243.63
| Facility | | $4,856.00 | $6,162.00 | $18,243.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.00 / $4,856.00 / $4,856.00
| Professional | | $2,398.00 | $4,856.00 | $4,856.00 |
- 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
- $5,965.41 / $5,965.41 / $5,965.41
| Professional | | $5,965.41 | $5,965.41 | $5,965.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,564.26 / $13,564.26 / $13,564.26
| Facility | | $13,564.26 | $13,564.26 | $13,564.26 |