- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.67 / $1,584.89 / $2,344.23
| Facility | | $44.67 | $1,584.89 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $52.48 / $2,691.53
| Professional | | $34.67 | $52.48 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,380.38 / $1,548.82
| Professional | | $1,174.90 | $1,380.38 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,548.82 / $2,398.83
| Professional | | $1,122.02 | $1,548.82 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,380.38 / $2,137.96
| Professional | | $645.65 | $1,380.38 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,174.90 / $1,174.90
| Professional | | $1,000.00 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $54.95 / $77.62
| Professional | | $39.81 | $54.95 | $77.62 |