- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,908.65 / $7,496.49 / $28,776.45
| Facility | | $1,908.65 | $7,496.49 | $28,776.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,142.64 / $3,859.17 / $7,125.00
| Professional | | $3,142.64 | $3,859.17 | $7,125.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.01 / $20.01 / $20.01
| Professional | | $20.01 | $20.01 | $20.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $367.47 / $367.47 / $367.47
| Facility | | $367.47 | $367.47 | $367.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.50 / $1,326.50 / $3,236.72
| Professional | | $1,326.50 | $1,326.50 | $3,236.72 |