- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,623.41 / $7,413.10
| Facility | | $3,801.89 | $5,623.41 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,888.44 / $7,585.78
| Professional | | $3,801.89 | $5,888.44 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $4,677.35 / $8,709.64
| Facility | | $1,737.80 | $4,677.35 | $8,709.64 |
- 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
- $4,168.69 / $7,244.36 / $10,000.00
| Facility | | $4,168.69 | $7,244.36 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,803.84 / $13,803.84 / $13,803.84
| Professional | | $13,803.84 | $13,803.84 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $6,918.31 / $12,022.64
| Facility | | $1,737.80 | $6,918.31 | $12,022.64 |