- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.10 / $4,932.34 / $11,783.04
| Facility | | $338.10 | $4,932.34 | $11,783.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,785.51 / $5,160.84 / $16,190.11
| Professional | | $3,785.51 | $5,160.84 | $16,190.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.91 / $3,467.91 / $3,467.91
| Professional | | $3,467.91 | $3,467.91 | $3,467.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.00 / $200.00 / $345.40
| Professional | | $120.00 | $200.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |