- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,047.13 / $8,128.31
| Facility | | $501.19 | $1,047.13 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- 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
- $21.38 / $38.02 / $50.12
| Professional | | $21.38 | $38.02 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $549.54 / $1,621.81
| Facility | | $269.15 | $549.54 | $1,621.81 |