- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.44 / $3,038.00 / $4,387.00
| Facility | | $172.44 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.44 / $172.44 / $580.32
| Professional | | $172.44 | $172.44 | $580.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $60.00
| Professional | | $45.00 | $45.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.00 / $2,764.75 / $3,252.65
| Professional | | $647.00 | $2,764.75 | $3,252.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,312.00 / $2,446.00 / $13,847.00
| Facility | | $2,312.00 | $2,446.00 | $13,847.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.65 / $761.60 / $1,566.72
| Professional | | $586.65 | $761.60 | $1,566.72 |