- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,693.00 / $6,094.85 / $7,943.37
| Facility | | $4,693.00 | $6,094.85 | $7,943.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.10 / $1,085.11 / $1,193.63
| Professional | | $1,085.10 | $1,085.11 | $1,193.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,085.11 / $1,833.85 / $14,198.40
| Facility | | $1,085.11 | $1,833.85 | $14,198.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,562.26 / $3,562.26 / $3,562.26
| Professional | | $3,562.26 | $3,562.26 | $3,562.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $10,061.00 / $15,899.59
| Facility | | $7,221.00 | $10,061.00 | $15,899.59 |