- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,466.84 / $7,943.28
| Facility | | $3,801.89 | $4,466.84 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,943.28 / $7,943.28
| Professional | | $3,801.89 | $7,943.28 | $7,943.28 |
- 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
- $3,801.89 / $7,943.28 / $12,589.25
| Facility | | $3,801.89 | $7,943.28 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $1,288.25 / $4,073.80
| Facility | | $64.57 | $1,288.25 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $1,288.25 / $4,073.80
| Professional | | $64.57 | $1,288.25 | $4,073.80 |