- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,344.23 / $2,344.23
| Facility | | $891.25 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $741.31 / $1,122.02
| Professional | | $79.43 | $741.31 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $43.65
| Professional | | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $70.79 / $1,000.00
| Professional | | $50.12 | $70.79 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.07 / $616.60 / $1,230.27
| Facility | | $66.07 | $616.60 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $43.65
| Professional | | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,096.48 / $1,949.84
| Professional | | $1,000.00 | $1,096.48 | $1,949.84 |