- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.21 / $1,059.21 / $1,059.21
| Professional | | $1,059.21 | $1,059.21 | $1,059.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.69 / $48.92 / $334.39
| Professional | | $37.69 | $48.92 | $334.39 |
- 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
- $1,059.21 / $1,059.21 / $1,472.30
| Facility | | $1,059.21 | $1,059.21 | $1,472.30 |
- 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 |