- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $969.41 / $1,130.00 / $4,089.80
| Facility | | $969.41 | $1,130.00 | $4,089.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,390.39 / $5,160.84 / $15,936.00
| Professional | | $4,390.39 | $5,160.84 | $15,936.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.03 / $0.03
| Facility | | $0.02 | $0.03 | $0.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,946.58 / $2,946.58 / $2,946.58
| Facility | | $2,946.58 | $2,946.58 | $2,946.58 |
- 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 |