- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $4,265.80 / $11,748.98
| Facility | | $630.96 | $4,265.80 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,128.61 / $16,218.10
| Professional | | $3,801.89 | $5,128.61 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $169.82 / $346.74
| Professional | | $120.23 | $169.82 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |