- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $4,813.58 / $15,000.00
| Facility | | $3,706.14 | $4,813.58 | $15,000.00 |
- 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
- $646.67 / $646.67 / $646.67
| Professional | | $646.67 | $646.67 | $646.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $7,228.00 / $12,680.00
| Facility | | $3,599.00 | $7,228.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.21 / $411.54 / $625.20
| Professional | | $329.21 | $411.54 | $625.20 |