- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $336.17 / $713.30 / $1,420.00
| Facility | | $336.17 | $713.30 | $1,420.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.18 / $314.18 / $436.73
| Professional | | $314.18 | $314.18 | $436.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $532.05 / $1,991.00 / $2,894.00
| Facility | | $532.05 | $1,991.00 | $2,894.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.01 / $8.01 / $8.01
| Professional | | $8.01 | $8.01 | $8.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.02 / $52.02 / $52.02
| Professional | | $52.02 | $52.02 | $52.02 |