- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $125.89 / $138.04
| Professional | | $61.66 | $125.89 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.29 / $4,570.88 / $5,370.32
| Facility | | $51.29 | $4,570.88 | $5,370.32 |
- 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
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $144.54 / $190.55
| Professional | | $85.11 | $144.54 | $190.55 |