- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.72 / $220.64 / $2,309.40
| Professional | | $99.72 | $220.64 | $2,309.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.38 / $2,289.21 / $2,289.21
| Professional | | $525.38 | $2,289.21 | $2,289.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $394.00 / $567.17 / $735.06
| Facility | | $394.00 | $567.17 | $735.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.00 / $735.06 / $961.03
| Professional | | $153.00 | $735.06 | $961.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.00 / $127.80 / $1,307.50
| Professional | | $4.00 | $127.80 | $1,307.50 |