- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.32 / $898.24 / $6,683.92
| Facility | | $402.32 | $898.24 | $6,683.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $1,261.46
| Professional | | $402.32 | $402.32 | $1,261.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.93 / $1,054.93 / $1,054.93
| Professional | | $1,054.93 | $1,054.93 | $1,054.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $2,500.00 / $2,500.00
| Professional | | $150.00 | $2,500.00 | $2,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.32 / $426.46 / $1,874.50
| Facility | | $402.32 | $426.46 | $1,874.50 |