- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,502.55 / $8,322.75 / $10,813.33
| Facility | | $3,502.55 | $8,322.75 | $10,813.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.94 / $3,306.43 / $4,972.50
| Professional | | $337.94 | $3,306.43 | $4,972.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.01 / $20.01 / $30.76
| Professional | | $20.01 | $20.01 | $30.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.93 / $1,054.93 / $1,054.93
| Professional | | $1,054.93 | $1,054.93 | $1,054.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $3,967.72
| Facility | | $402.32 | $402.32 | $3,967.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.00 / $155.00 / $329.00
| Professional | | $155.00 | $155.00 | $329.00 |