- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,910.00 / $3,977.00 / $13,531.45
| Facility | | $2,910.00 | $3,977.00 | $13,531.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.45 / $1,109.30 / $13,531.45
| Professional | | $1,023.45 | $1,109.30 | $13,531.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.70 / $751.45 / $1,084.55
| Professional | | $488.70 | $751.45 | $1,084.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,556.00 / $4,495.00
| Facility | | $1,078.00 | $1,556.00 | $4,495.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.62 / $653.10 / $1,305.29
| Professional | | $135.62 | $653.10 | $1,305.29 |