- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.00 / $771.00 / $1,952.00
| Professional | | $771.00 | $771.00 | $1,952.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $7,129.36 / $7,921.51
| Facility | | $0.02 | $7,129.36 | $7,921.51 |
- 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
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |