- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,274.00 / $2,246.40 / $2,246.40
| Facility | | $1,274.00 | $2,246.40 | $2,246.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $50.00 / $2,246.40
| Professional | | $30.00 | $50.00 | $2,246.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.70 / $474.79 / $1,107.83
| Facility | | $118.70 | $474.79 | $1,107.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.77 / $878.50 / $2,055.30
| Professional | | $263.77 | $878.50 | $2,055.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.00 / $1,500.00 / $2,150.00
| Professional | | $1,050.00 | $1,500.00 | $2,150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $59.00 / $71.00
| Professional | | $45.00 | $59.00 | $71.00 |