- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,387.21 / $26,302.68 / $26,302.68
| Facility | | $22,387.21 | $26,302.68 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $50.12 / $50.12
| Professional | | $50.12 | $50.12 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,548.13 / $4,265.80
| Facility | | $3,162.28 | $3,548.13 | $4,265.80 |
- 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 / $4,466.84
| Facility | | $64.57 | $64.57 | $4,466.84 |