- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $528.24 / $1,186.00 / $2,825.00
| Facility | | $528.24 | $1,186.00 | $2,825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.95 / $872.21 / $1,946.48
| Professional | | $783.95 | $872.21 | $1,946.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.00 / $1,642.00 / $1,642.00
| Professional | | $1,642.00 | $1,642.00 | $1,642.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.00 / $6,242.00 / $15,000.00
| Facility | | $1,185.00 | $6,242.00 | $15,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.76 / $998.22 / $2,065.71
| Professional | | $782.76 | $998.22 | $2,065.71 |