- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $325.61 / $1,320.00 / $2,825.00
| Facility | | $325.61 | $1,320.00 | $2,825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.62 / $325.61 / $495.62
| Professional | | $185.62 | $325.61 | $495.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.00 / $1,357.00 / $1,357.00
| Professional | | $1,357.00 | $1,357.00 | $1,357.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $25.00 / $50.00
| Professional | | $17.00 | $25.00 | $50.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $624.00 / $1,223.00 / $5,253.00
| Facility | | $624.00 | $1,223.00 | $5,253.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $434.25 / $643.27 / $1,327.71
| Professional | | $434.25 | $643.27 | $1,327.71 |