- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $7,244.36
| Facility | | $4,897.79 | $4,897.79 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $707.95 / $1,621.81
| Professional | | $446.68 | $707.95 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $537.03 / $851.14
| Professional | | $407.38 | $537.03 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $537.03 / $1,174.90
| Professional | | $389.05 | $537.03 | $1,174.90 |