- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,496.07 / $5,463.90 / $9,227.40
| Facility | | $1,496.07 | $5,463.90 | $9,227.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,835.50 / $5,160.84 / $15,620.00
| Professional | | $4,835.50 | $5,160.84 | $15,620.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,456.92 / $5,821.21 / $8,577.84
| Facility | | $5,456.92 | $5,821.21 | $8,577.84 |
- 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
- $4,480.00 / $4,480.00 / $4,480.00
| Facility | | $4,480.00 | $4,480.00 | $4,480.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.91 / $3,467.91 / $3,467.91
| Professional | | $3,467.91 | $3,467.91 | $3,467.91 |