- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,022.80 / $7,601.22 / $11,114.34
| Facility | | $3,022.80 | $7,601.22 | $11,114.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $4,972.50
| Professional | | $402.32 | $402.32 | $4,972.50 |
- 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
- $1,054.93 / $1,054.93 / $1,054.93
| Professional | | $1,054.93 | $1,054.93 | $1,054.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $493.00
| Professional | | $200.00 | $200.00 | $493.00 |