- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $7,244.36 / $8,128.31
| Facility | | $4,073.80 | $7,244.36 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,584.89 / $4,073.80
| Professional | | $389.05 | $1,584.89 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $691.83 / $3,090.30
| Professional | | $426.58 | $691.83 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,412.54 / $2,691.53
| Professional | | $371.54 | $1,412.54 | $2,691.53 |