- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $7,079.46 / $25,118.86
| Facility | | $794.33 | $7,079.46 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,089.30 / $5,011.87
| Professional | | $1,000.00 | $2,089.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $1,584.89 / $5,128.61
| Professional | | $416.87 | $1,584.89 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,187.76 / $4,265.80
| Professional | | $1,380.38 | $2,187.76 | $4,265.80 |