- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,264.65 / $3,730.92 / $5,974.62
| Facility | | $3,264.65 | $3,730.92 | $5,974.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.58 / $1,545.58 / $1,545.58
| Professional | | $1,545.58 | $1,545.58 | $1,545.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.62 / $27.53 / $66.79
| Facility | | $18.62 | $27.53 | $66.79 |
- 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
- $4,480.00 / $4,480.00 / $4,480.00
| Facility | | $4,480.00 | $4,480.00 | $4,480.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.66 / $660.66 / $660.66
| Professional | | $660.66 | $660.66 | $660.66 |