- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $4,067.51 / $4,067.51
| Facility | | $0.02 | $4,067.51 | $4,067.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $15,031.10
| Professional | | $0.02 | $0.02 | $15,031.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,384.41 / $3,506.48 / $3,506.48
| Professional | | $2,384.41 | $3,506.48 | $3,506.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,519.47 / $3,015.61 / $4,382.34
| Facility | | $1,519.47 | $3,015.61 | $4,382.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.41 / $2,344.04 / $3,513.88
| Professional | | $2,010.41 | $2,344.04 | $3,513.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.81 / $1,402.59 / $2,337.65
| Professional | | $981.81 | $1,402.59 | $2,337.65 |