- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.12 / $2,095.00 / $7,838.38
| Facility | | $308.12 | $2,095.00 | $7,838.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.12 / $318.64 / $318.64
| Professional | | $308.12 | $318.64 | $318.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $85.00 / $3,500.00
| Professional | | $50.00 | $85.00 | $3,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.00 / $5,060.00 / $17,636.00
| Facility | | $582.00 | $5,060.00 | $17,636.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.21 / $482.97 / $666.45
| Professional | | $407.21 | $482.97 | $666.45 |