- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $10,715.19 / $47,863.01
| Facility | | $3,981.07 | $10,715.19 | $47,863.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $199.53 / $4,897.79
| Professional | | $93.33 | $199.53 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,890.45
| Professional | | $3,801.89 | $3,801.89 | $3,890.45 |