- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $249.05 / $1,040.00 / $3,825.80
| Facility | | $249.05 | $1,040.00 | $3,825.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.21 / $1,082.03 / $2,493.91
| Professional | | $249.21 | $1,082.03 | $2,493.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.00 / $600.00 / $600.00
| Professional | | $600.00 | $600.00 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.70 / $583.39 / $2,656.01
| Professional | | $277.70 | $583.39 | $2,656.01 |
- 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
- $225.00 / $513.00 / $1,581.00
| Facility | | $225.00 | $513.00 | $1,581.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.56 / $1,763.84 / $3,683.74
| Professional | | $1,180.56 | $1,763.84 | $3,683.74 |