- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,630.18 / $18,792.75 / $60,954.50
| Facility | | $1,630.18 | $18,792.75 | $60,954.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.18 / $1,630.18 / $1,630.18
| Professional | | $1,630.18 | $1,630.18 | $1,630.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $11.98
| Professional | | $0.02 | $0.02 | $11.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,630.18 / $1,630.18 / $2,482.76
| Facility | | $1,630.18 | $1,630.18 | $2,482.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,291.00 / $1,291.00 / $4,071.00
| Facility | | $1,291.00 | $1,291.00 | $4,071.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.00 / $1,291.00 / $4,071.00
| Professional | | $1,291.00 | $1,291.00 | $4,071.00 |