- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,796.47 / $3,796.47 / $5,622.58
| Facility | | $3,796.47 | $3,796.47 | $5,622.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,840.00 / $11,983.98 / $23,152.50
| Professional | | $6,840.00 | $11,983.98 | $23,152.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $178.78 / $422.36 / $1,044.50
| Facility | | $178.78 | $422.36 | $1,044.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.03 / $0.03
| Professional | | $0.02 | $0.03 | $0.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $76.00 / $100.00 / $100.00
| Facility | | $76.00 | $100.00 | $100.00 |