- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $3,630.78 / $7,413.10
| Facility | | $954.99 | $3,630.78 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $371.54 / $2,344.23
| Professional | | $89.13 | $371.54 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,467.37 / $7,585.78
| Facility | | $794.33 | $3,467.37 | $7,585.78 |
- 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
- $213.80 / $1,513.56 / $2,511.89
| Facility | | $213.80 | $1,513.56 | $2,511.89 |