- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,466.84 / $10,232.93
| Facility | | $1,548.82 | $4,466.84 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.95 / $27.54 / $67.61
| Facility | | $19.95 | $27.54 | $67.61 |
- 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
- $64.57 / $64.57 / $4,466.84
| Facility | | $64.57 | $64.57 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |