- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.23 / $8,024.94 / $17,494.37
| Facility | | $8.23 | $8,024.94 | $17,494.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,785.51 / $5,311.60 / $16,190.11
| Professional | | $3,785.51 | $5,311.60 | $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
- Facility
- Modifier
- Low / Median / High Price
- $6,709.09 / $6,709.09 / $6,709.09
| Facility | | $6,709.09 | $6,709.09 | $6,709.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |