- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Facility | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $891.25 / $1,412.54
| Professional | | $602.56 | $891.25 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,041.74 / $2,041.74
| Professional | | $1,288.25 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $93.33 / $93.33
| Professional | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38,018.94 / $38,018.94 / $38,018.94
| Professional | | $38,018.94 | $38,018.94 | $38,018.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $112.20 / $1,000.00
| Facility | | $100.00 | $112.20 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $95.50 / $812.83
| Professional | | $67.61 | $95.50 | $812.83 |