- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $6,456.54 / $8,709.64
| Facility | | $1,202.26 | $6,456.54 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,479.11
| Professional | | $1,202.26 | $1,202.26 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $2,187.76
| Facility | | $1,202.26 | $1,202.26 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $776.25 / $1,949.84
| Facility | | $204.17 | $776.25 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |