- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.84 / $62.84 / $114.86
| Professional | | $62.84 | $62.84 | $114.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.89 / $4,602.68 / $5,507.87
| Facility | | $56.89 | $4,602.68 | $5,507.87 |
- 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
- $2,654.00 / $4,571.00 / $7,350.00
| Facility | | $2,654.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.16 / $137.47 / $176.96
| Professional | | $85.16 | $137.47 | $176.96 |