- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,918.51 / $8,330.12 / $15,403.37
| Facility | | $3,918.51 | $8,330.12 | $15,403.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,859.17 / $3,918.51 / $8,775.00
| Professional | | $3,859.17 | $3,918.51 | $8,775.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $11.98
| Professional | | $0.02 | $0.02 | $11.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.50 / $1,326.50 / $1,326.50
| Professional | | $1,326.50 | $1,326.50 | $1,326.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,859.17 / $3,918.51 / $5,967.89
| Facility | | $3,859.17 | $3,918.51 | $5,967.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,291.00 / $1,291.00 / $4,071.00
| Facility | | $1,291.00 | $1,291.00 | $4,071.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.00 / $1,291.00 / $4,071.00
| Professional | | $1,291.00 | $1,291.00 | $4,071.00 |