- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $6,165.95 / $22,387.21
| Facility | | $1,862.09 | $6,165.95 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,128.61 / $16,218.10
| Professional | | $2,187.76 | $5,128.61 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,606.93 / $9,549.93
| Facility | | $5,128.61 | $6,606.93 | $9,549.93 |