- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.71 / $1,320.00 / $2,825.00
| Facility | | $380.71 | $1,320.00 | $2,825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.88 / $339.70 / $483.51
| Professional | | $253.88 | $339.70 | $483.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.00 / $1,326.00 / $1,326.00
| Professional | | $1,326.00 | $1,326.00 | $1,326.00 |
- 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
- $356.26 / $527.75 / $1,089.26
| Professional | | $356.26 | $527.75 | $1,089.26 |