- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $1,905.46 / $1,905.46
| Facility | | $331.13 | $1,905.46 | $1,905.46 |
- 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 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $3.80 / $3.80
| Professional | | $0.02 | $3.80 | $3.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $50,118.72
| Facility | | $64.57 | $64.57 | $50,118.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $12.02 / $12.02
| Professional | | $12.02 | $12.02 | $12.02 |