- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $825.52 / $1,035.25 / $4,207.38
| Facility | | $825.52 | $1,035.25 | $4,207.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.00 / $516.61 / $1,035.25
| Professional | | $115.00 | $516.61 | $1,035.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $3.23
| Professional | | $0.02 | $0.02 | $3.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.34 / $489.34 / $489.34
| Professional | | $489.34 | $489.34 | $489.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.89 / $2,371.46 / $3,328.36
| Professional | | $1,410.89 | $2,371.46 | $3,328.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $3,000.00 / $4,410.00
| Professional | | $2,500.00 | $3,000.00 | $4,410.00 |