- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,859.17 / $12,345.75 / $37,733.79
| Facility | | $3,859.17 | $12,345.75 | $37,733.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,859.17 / $5,231.70 / $9,251.04
| Professional | | $3,859.17 | $5,231.70 | $9,251.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.01 / $20.01 / $20.01
| Professional | | $20.01 | $20.01 | $20.01 |
- 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
- $200.00 / $200.00 / $493.00
| Professional | | $200.00 | $200.00 | $493.00 |