- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $9,120.11 / $25,703.96
| Facility | | $2,398.83 | $9,120.11 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $2,398.83 / $2,398.83
| Professional | | $95.50 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,162.28 / $6,165.95
| Facility | | $2,398.83 | $3,162.28 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $2,398.83 / $4,365.16
| Facility | | $100.00 | $2,398.83 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Professional | | $2,398.83 | $2,398.83 | $2,398.83 |