- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,987.50 / $3,038.00 / $4,387.00
| Facility | | $1,987.50 | $3,038.00 | $4,387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,987.50 / $1,987.50 / $2,332.00
| Professional | | $1,987.50 | $1,987.50 | $2,332.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $439.95 / $677.88 / $6,162.19
| Professional | | $439.95 | $677.88 | $6,162.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $80.00
| Professional | | $30.00 | $45.00 | $80.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,312.00 / $2,446.00 / $13,847.00
| Facility | | $2,312.00 | $2,446.00 | $13,847.00 |