- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,540.77 / $5,540.77 / $5,908.19
| Facility | | $5,540.77 | $5,540.77 | $5,908.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,759.30 / $4,759.30 / $4,759.30
| Professional | | $4,759.30 | $4,759.30 | $4,759.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.06 / $0.09
| Facility | | $0.02 | $0.06 | $0.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,540.77 / $5,908.19 / $8,097.46
| Facility | | $5,540.77 | $5,908.19 | $8,097.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,759.30 / $4,759.30 / $4,759.30
| Professional | | $4,759.30 | $4,759.30 | $4,759.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |