- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,940.29 / $16,103.02
| Facility | | $4,265.80 | $6,940.29 | $16,103.02 |
- 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
- 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
- $660.66 / $660.66 / $660.66
| Professional | | $660.66 | $660.66 | $660.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $1,750.00 / $10,945.00
| Facility | | $100.00 | $1,750.00 | $10,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $1,750.00 / $10,945.00
| Professional | | $100.00 | $1,750.00 | $10,945.00 |