- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $1,040.00 / $1,831.00
| Facility | | $500.00 | $1,040.00 | $1,831.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.97 / $925.64 / $1,335.87
| Professional | | $224.97 | $925.64 | $1,335.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.87 / $455.87 / $455.87
| Professional | | $455.87 | $455.87 | $455.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.50 / $42.50 / $50.00
| Professional | | $42.50 | $42.50 | $50.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $624.00 / $1,236.00 / $5,253.00
| Facility | | $624.00 | $1,236.00 | $5,253.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.96 / $1,159.02 / $1,608.82
| Professional | | $580.96 | $1,159.02 | $1,608.82 |