- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,489.01 / $3,873.14 / $4,705.58
| Professional | | $3,489.01 | $3,873.14 | $4,705.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $680.00 / $17,459.25
| Facility | | $680.00 | $680.00 | $17,459.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,893.14 / $1,893.14 / $1,893.14
| Professional | | $1,893.14 | $1,893.14 | $1,893.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,738.29 / $4,683.10 / $7,334.93
| Professional | | $3,738.29 | $4,683.10 | $7,334.93 |