- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,677.35 / $25,703.96
| Facility | | $2,398.83 | $4,677.35 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Professional | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $60.26 / $60.26
| Professional | | $45.71 | $60.26 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,235.94
| Facility | | $2,398.83 | $2,398.83 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |