- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,168.69 / $9,772.37
| Facility | | $1,122.02 | $4,168.69 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $5,623.41 / $11,481.54
| Professional | | $1,023.29 | $5,623.41 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $199.53 / $346.74
| Professional | | $120.23 | $199.53 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,951.21 / $7,413.10
| Facility | | $575.44 | $2,951.21 | $7,413.10 |