- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.00 / $4,519.87 / $57,006.69
| Facility | | $2,398.00 | $4,519.87 | $57,006.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.00 / $2,398.00 / $2,453.46
| Professional | | $2,398.00 | $2,398.00 | $2,453.46 |
- 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
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,965.41 / $5,965.41 / $5,965.41
| Professional | | $5,965.41 | $5,965.41 | $5,965.41 |