- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $16,595.87 / $52,480.75
| Facility | | $1,621.81 | $16,595.87 | $52,480.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $15,848.93
| Professional | | $1,621.81 | $1,621.81 | $15,848.93 |
- 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
- $1,621.81 / $1,621.81 / $15,848.93
| Facility | | $1,621.81 | $1,621.81 | $15,848.93 |
- 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 |