- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $406.21 / $1,320.00 / $2,825.00
| Facility | | $406.21 | $1,320.00 | $2,825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.86 / $362.45 / $515.89
| Professional | | $270.86 | $362.45 | $515.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,184.00 / $2,184.00 / $2,184.00
| Professional | | $2,184.00 | $2,184.00 | $2,184.00 |
- 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
- $400.94 / $576.10 / $1,163.19
| Professional | | $400.94 | $576.10 | $1,163.19 |