- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $615.00 / $1,245.00 / $2,767.50
| Facility | | $615.00 | $1,245.00 | $2,767.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $592.50 / $615.00 / $712.50
| Professional | | $592.50 | $615.00 | $712.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.73 / $2,250.00 / $4,071.75
| Facility | | $10.73 | $2,250.00 | $4,071.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.73 / $10.73 / $453.75
| Professional | | $10.73 | $10.73 | $453.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $750.00 / $937.50 / $16,533.81
| Facility | | $750.00 | $937.50 | $16,533.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.00 / $825.00 / $1,012.50
| Professional | | $750.00 | $825.00 | $1,012.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $487.50 / $1,417.72 / $2,924.31
| Facility | | $487.50 | $1,417.72 | $2,924.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.16 / $861.93 / $1,077.41
| Professional | | $14.16 | $861.93 | $1,077.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.00 / $450.00 / $750.00
| Professional | | $315.00 | $450.00 | $750.00 |