- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.00 / $1,201.00 / $1,201.00
| Professional | | $1,201.00 | $1,201.00 | $1,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.45 / $358.02 / $497.12
| Professional | | $283.45 | $358.02 | $497.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $800.00 / $4,638.64 / $6,184.85
| Facility | | $800.00 | $4,638.64 | $6,184.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.00 / $1,201.00 / $1,669.39
| Facility | | $1,201.00 | $1,201.00 | $1,669.39 |
- 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
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.40 / $2,138.63 / $2,138.63
| Facility | | $760.40 | $2,138.63 | $2,138.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,138.63 / $2,138.63 / $2,138.63
| Professional | | $2,138.63 | $2,138.63 | $2,138.63 |