- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.88 / $2,398.83 / $12,302.69
| Facility | | $58.88 | $2,398.83 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $4,897.79
| Professional | | $2,398.83 | $2,398.83 | $4,897.79 |
- 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
- $2,398.83 / $2,454.71 / $4,786.30
| Facility | | $2,398.83 | $2,454.71 | $4,786.30 |
- 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 |