- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,047.13 / $1,995.26
| Facility | | $501.19 | $1,047.13 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,041.74
| Professional | | $1,995.26 | $1,995.26 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $107.15
| Professional | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $1,000.00
| Facility | | $223.87 | $223.87 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $107.15
| Professional | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $38.02 / $50.12
| Professional | | $21.38 | $38.02 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $562.34 / $1,621.81
| Facility | | $295.12 | $562.34 | $1,621.81 |