- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,215.97 / $9,918.87 / $20,473.25
| Facility | | $4,215.97 | $9,918.87 | $20,473.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,859.17 / $3,859.17 / $9,251.04
| Professional | | $3,859.17 | $3,859.17 | $9,251.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.50 / $1,326.50 / $1,326.50
| Professional | | $1,326.50 | $1,326.50 | $1,326.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $345.40
| Professional | | $100.00 | $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 |