- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $5,370.32 / $12,022.64
| Facility | | $1,778.28 | $5,370.32 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,332.54 / $21,379.62
| Facility | | $4,570.88 | $9,332.54 | $21,379.62 |
- 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
- $64.57 / $64.57 / $2,511.89
| Facility | | $64.57 | $64.57 | $2,511.89 |