- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $563.24 / $6,025.68 / $7,982.70
| Facility | | $563.24 | $6,025.68 | $7,982.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $3,002.19
| Professional | | $402.32 | $402.32 | $3,002.19 |
- 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
- 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 |