- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.25 / $1,430.00 / $2,151.50
| Facility | | $21.25 | $1,430.00 | $2,151.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $38.00 / $1,965.86
| Professional | | $30.00 | $38.00 | $1,965.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.20 / $1,136.46 / $1,890.72
| Professional | | $928.20 | $1,136.46 | $1,890.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.00 / $1,717.50 / $2,306.00
| Professional | | $1,250.00 | $1,717.50 | $2,306.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.00 / $1,690.00 / $2,668.64
| Professional | | $780.00 | $1,690.00 | $2,668.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.00 / $50.00 / $79.00
| Professional | | $35.00 | $50.00 | $79.00 |